CHORLEYWOOD
Chorleywood's
Boutique Gym
01923 283845
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Fitness to Fit Your Lifestyle - Classes available 24/7
Physical Activity Readiness Questionnaire (PAR-Q)
Please fill out the following form in order to participate in our activity.
First Name
Last Name
Date of Birth
Email
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
No
Yes
Do you feel pain in your chest when you do physical activity?
No
Yes
In the past month, have you had a chest pain when you were not doing physical activity?
No
Yes
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?
No
Yes
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?
No
Yes
Is your doctor currently prescribing medication for your blood pressure or heart condition?
No
Yes
Do you know of any other reason why you should not take part in physical activity?
No
Yes
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury for which I am personally responsible.
Your Signature
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