Forms - Please complete before Starting at the Studio

Physical Activity Readiness Questionnaire (PAR-Q)

If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Common sense is your best guide when answering these questions. Please read

carefully and answer each one honestly: check YES or NO.

First name

Last name

Email

Phone

Birthday

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

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

Yes

No

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

Yes

No

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

Yes

No

Do you lose you balance because of dizziness or do you ever lose conciousness?

Yes

No

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?

Yes

No

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes

No

Do you know of any other reason why you should not do physical activity? If yes, please comment:

Yes

No

If yes, please comment..

If you have answered NO to all questions:

It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A

fitness appraisal can help determine your ability levels.

If you have answered YES to one or more questions:

You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and

in your current state of health. Having answered YES to one of the above, I confirm I have sought medical advice and my GP has agreed that I may exercise.

I confirm 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.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

This physical activity clearance becomes invalid if your condition changes so that you would answer YES to any of the 7 questions.