PAR-Q Form

PAR-Q Physical Activity Readiness Questionnaire

• Client:

• Document No.

• Completed on:

  Date

Personal details:

• Contact details:

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• Address:

• Telephone numbers:

• Email Address:

Confidential Questions::

• PLEASE READ CAREFULLY<br>If you answer YES to any of the questions below, you may need your doctors consent before you participate in Nordic Walking. Continuing to participate after answering YES to any of the questions is at your own risk.

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• Has a doctor ever said that you have a heart condition and recommended only medical supervised activity?

  Yes

  No

• Do you have chest pain brought on by physical activity?

  Yes

  No

• Have you developed chest pain in the last month?

  Yes

  No

• Do you lose consciousness or fall over as a result of dizziness?

  Yes

  No

• Do you have a bone or joint problem that could be aggravated by physical activity?

  Yes

  No

• Has a doctor ever recommended medication for your blood pressure or a heart condition?

  Yes

  No

• Are you aware through your own experience or from a doctors advice of any other reason why you should not exercise without medical supervision?

  Yes

  No

• Please outline any other relevant information that may affect your ability to exercise.

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• Here existing medical conditions:

• Current medication:

• Known allergies:

• I realise that my bodies reaction to exercise is not totally predictable. Should I develop a condition that affects my ability to exercise, I will inform my instructor immediately and stop exercising if necessary. I take full responsibility for monitoring my own physical condition at all times.

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IN CASE OF EMERGENCY:

• Select to see emergency contact details.

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• Name:

• Phone number:

• Address:

• Relationship:

Lastly:

• Select here if you do not wish to be kept informed of Nordic Walking courses, classes and other events.