Physical Activity Readiness Questionnaire - ParQ

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact *

(###)

###

####

Have you ever had a heart attack, stroke, open heart surgery or any other coronary heart disease? *

Yes

No

Do you ever experience pain or tightness in the chest whilst at rest or normal activities? *

Yes

No

Have you ever been diagnosed with high blood pressure? *

Yes

No

Have you or do you suffer from any respiratory problems (asthma, pneumonia) or any allergies? *

Yes

No

Do you know of any blood relatives who have had any coronary heart disease (stroke, heart attack, bypass surgery), before the age of 50? *

Yes

No

Have you any metabolic problems (diabetes, thyroids, obesity)? *

Yes

No

Have you suffered or do you suffer from any neuromuscular, orthopaedic or arthritic problems (epilepsy, convulsions, broken bones, knee or back problems)? *

Yes

No

Have you ever suffered a major illness or had major surgery? *

Yes

No

Have you suffered any injuries to the neck, shoulders, arms, back, hips, legs or joints? *

Yes

No

Have you ever had a soft tissue injury lasting for 12 weeks or more? *

Yes

No

Are there any other medical problems or information that you feel your health fitness consultant should know about before undertaking any form of training? *

Yes

No

Terms & Conditions *

Unstaffed Hours Terms & Conditions To gain access to the Gym during our unstaffed hours you must have the following: 1. Be 18+ years old and competent on all machines & equipment in the Gym. 2. Have an up to date paid membership with active key fob. replacement fobs are £5.00. 3. Have had your photo taken for our data base. Gaining entry to the Gym when we are closed is a privilege and should not be taken for granted. If we think it necessary to do so, we will deactivate your Fob. To ensure your Fob does not get deactivated please follow these simple instructions: 1. Keep an up to date paid membership. 2. Do not let others into the Gym using your fob. Everyone must sign himself or herself in. 3. Keep the areas and equipment that you use clean and tidy. Cleaning equipment is provided if needed. 4. Report all accidents and breakages on the forms provided at the reception desk. 5. Make sure all exercise is correct and controlled at all times. 6. Do not abuse any equipment or other Gym users. 7. CCTV is operational across the entire Gym. This must not be tampered with. 8. All doors and windows must be kept closed during the unstaffed hours. 9. Bring a mobile phone with you to call for help in the case of an emergency or use the Gym phone in reception on the windowsill.

Agree

Signed (type) *

First Name

Last Name

Date *

MM

DD

YYYY