Physical Activity Readiness Questionnaire

Name *

Date of Birth *

Gender

Phone number *

Email *

Name Of GP / Location *

Blood Pressure (If Known)

Current Exercise Sessions / Week

Next of Kin Name *

Next Of Kin Phone Number *

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? YES/NO *

Yes

No

2. Do you feel pain in your chest when you do physical activity? YES/NO *

Yes

No

3. In the past month, have you had chest pain when you were not doing physical activity? YES/NO *

Yes

No

4. Do you lose your balance because of dizziness or do you ever lose consciousness? YES/NO *

Yes

No

5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in physical activity? YES/NO *

Yes

No

6. Is your doctor currently prescribing drugs for your blood pressure or heart condition? YES/NO *

Yes

No

7. Do you suffer from asthma or need to carry a inhaler with you? YES/NO *

Yes

No

8. Do you know of any other possible reason why you should not take part physical activity? YES/NO *

Yes

No

If you answered "YES" to any of the above, please add more information in as much detail as you can here:

I understand that full payment will still apply for cancellations made under 24 hours before the scheduled session *

Yes

Sign Name *

Date *

Name of Parent or Guardian (If Under 18)

I confirm all the information submitted above is correct *

.

Verification Code *

Physical Activity Readiness Questionnaire.