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Chorleywood's
Independent Gym
01923 283845
CHORLEYWOOD
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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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Submit
Thanks for submitting!
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