PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

This questionnaire is for people aged 15 – 69 years old, looking to take part in physical activity, and is a legal requirement. Common sense is your best guide when you answer these questions. Your health and wellbeing is your responsibility, so take the time to answer the questions honestly.

If you answered YES to any of the questions then you will need to consult your doctor BEFORE engaging in any services offered by myself (Justin Emmerson). I can only work off the information you supply, by submitting this form you are confirming that you are physically healthy enough to engage in physical exercise.

If anything changes after submission, it is your duty to cease exercise and inform me. Once you have completed the below ParQ form, a copy will be sent to both of us.

Par Q Form

First Name

Last Name

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart conditions?

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?

Do you know of any other reason why you should not do physical activity?

Please read the below carefully …

1. Explanation of the exercise test – you will perform a number of exercise tests. The exercise intensity of each will be at a level appropriate to your ability. I may stop the test at any time because of signs of fatigue or, you may stop when you wish because of personal feelings of fatigue or discomfort.

2. Risks and discomforts – there exists the possibility of certain changes occurring during the test. They include abnormal blood pressure, fainting, disorder of heartbeat and in rare instances, heart attack, stroke or death. Every effort will be made to minimise these risks by evaluation of preliminary information relating to your health and fitness and by observations during testing. Trained personnel are available to deal with unusual situations that may arise.

3. Responsibilities of the client – information you possess about your health status or previous experiences of unusual feelings with physical effort may affect the safety and value of your exercise tests. Prompt reporting of feelings of effort during the exercise tests are of great importance. It is your responsibility to fully disclose such information when requested.

4. Benefits to be expected – the results obtained from the exercise tests will assist in evaluating what type of physical activities you may participate in.

5. Injuries – any questions about the procedures used in the exercise tests are encouraged. If you have any doubts or questions, please ask for further explanations.

6. Freedom of consent – your permission to perform the exercise tests is voluntary. You are free to deny consent or stop at any point, if you so desire.

I have read this form and I understand the test procedures that I will perform. I consent to participate.

Todays Date

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Name

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart conditions?

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?

Do you know of any other reason why you should not do physical activity?

1. Explanation of the exercise test - you will perform a number of exercise tests. The exercise intensity of each will be at a level appropriate to your ability. I may stop the test at any time because of signs of fatigue or, you may stop when you wish because of personal feelings of fatigue or discomfort.

2. Risks and discomforts - there exists the possibility of certain changes occurring during the test. They include abnormal blood pressure, fainting, disorder of heartbeat and in rare instances, heart attack, stroke or death. Every effort will be made to minimise these risks by evaluation of preliminary information relating to your health and fitness and by observations during testing. Trained personnel are available to deal with unusual situations that may arise.

3. Responsibilities of the client -information you possess about your health status or previous experiences of unusual feelings with physical effort may affect the safety and value of your exercise tests. Prompt reporting of feelings of effort during the exercise tests are of great importance. It is your responsibility to fully disclose such information when requested.

4. Benefits to be expected- the results obtained from the exercise tests will assist in evaluating what type of physical activities you may participate in.

5. Injuries - any questions about the procedures used in the exercise tests are encouraged. If you have any doubts or questions, please ask for further explanations.

6. Freedom of consent - your permission to perform the exercise tests is voluntary. You are free to deny consent or stop at any point, if you so desire.

I have read this form and I understand the test procedures that I will perform. I consent to participate.

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

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