Physical Activity Health Questionnaire

If you’re aged 15-69, the PAR-Q will tell you if you should check with your doctor before significantly changing your physical activity patterns. If you’re over 69 years and aren’t used to being very active, check with your doctor. Please read each question carefully and answer honestly by ticking YES/NO

Health Declaration

Please fill out the following form
in order to participate in our activity.

First Name

Last Name

Date of Birth

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? Or is your doctor currently prescribing medicaion for your blood presurre or a heart condition?

Yes

Do you feel pain in your chest when you do or do not do physical activity? or Do you witness dizziness or loss of consciousness?

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?

Yes

If you answered yes to any question, please elaborate

If you answered YES to one or more questions: You should consult with your doctor to clarify that it’s safe for you to become physically active at the current time.

If you answered NO to ALL of the questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.

I declare that the info I’ve provided is accurate & complete and that 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.

Digital Signature

Thanks for submitting!

Physical Activity Health Questionnaire

Health Declaration

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