Physical Activity Readiness Questionnaire (PAR-Q) - Member
Name Date
Address
Emergency Contact Name Emergency Phone Number
Prior to participating in physical activity on the premises of Train Fitness International Limited (“the Company”) you are required to
complete this PAR-Q together with the Informed Consent and Release and Waiver Form (‘ICRW’). For most people, physical activity
should not pose any problem or hazard, however, potential risks, whilst not apparent at rest, may be exacerbated by an increase in levels of
physical activity. The PAR-Q is designed to identify the small number of adults for whom physical activity might be inappropriate or those
who should seek medical advice concerning the type of physical activity most suitable for them.
The ICRW should be read in conjunction with this PAR-Q. You must not undertake physical activity on the premises of the Company unless
you have completed, signed, and actioned (as necessary) both your PAR-Q and ICRW.
Please complete the questionnaire below by reading each question carefully and ticking the response that applies to you. You are wholly
responsible for your answers and if you are in any doubt you must seek medical advice.
Medical Background Yes No
Has your doctor ever said that you have a bone or joint problem, such as arthritis, or any medical condition,
1.
surgical operation or injury that has been aggravated by physical activity or might be made worse with exercise?
2. Do you have high blood pressure?
3. Do you have low blood pressure?
4. Do you have Diabetes Mellitus or any other metabolic disease?
5. Has your doctor ever said you have raised cholesterol (serum level above 6.2mmol/L)?
Has your doctor ever said that you have a heart condition and that you should only do physical activity
6.
recommended by a doctor?
7. Have you ever felt pain in your chest when you do physical activity or at rest?
8. Is your doctor currently prescribing you medication?
9. Have you ever suffered from unusual shortness of breath at rest or with mild exertion?
10. Is there any history of coronary heart disease in your family?
11. Do you often feel faint, have spells of severe dizziness or have you ever lost consciousness?
12. Do you suffer from regular head aches, dizziness, fainting or fits?
13. Are you, or is there any possibility that you might be pregnant?
14. Do you know of any other reason why you should not participate in a programme of physical activity?
If you answered:
‘Yes’ to one or more questions:
You must consult your doctor before undertaking any physical activity on the premises of the Company. You will need to discuss the
nature of the physical activity you are about to undertake and either present your PAR-Q or tell your doctor which questions you
answered ‘yes’ to. Your doctor needs to advise you as to your suitability for unrestricted physical activity.
‘No’ to all questions:
You acknowledge that you are taking responsibility for the accuracy of your replies and the decision that you are physically fit enough for
unrestricted physical activity.
By signing this PAR-Q I confirm that I have read, understood and correctly answered the questions set out above. I wish to undertake
physical activities that may include but shall not be limited to aerobic, anaerobic, flexibility, stability, resistance, muscular strength and
endurance exercise. I understand that undertaking these physical activities involves the risk of injury and even the possibility of death.
I confirm I am voluntarily undertaking a level of physical activity that I consider acceptable and appropriate to my level of fitness
and overall health. If I have answered ‘yes’ to any of the questions above, by signing this form I am also confirming that I have taken
medical advice relating to my performance of physical activity and my doctor has confirmed I am fit enough.
Name: Signature: Date:
Version 16.10.2019 | #FitForPurpose
