PAR-Q ABLE FITNESS PAR-Q Name Address Email Contact Number Emergency Contact Name Emergency Contact Number Do you have a bone or a joint problem such as arthritis, which has been aggravated by exercise or might be made worse with exercise? YES NO To your knowledge, do you have high blood pressure? YES NO Do you have Diabetes or any other metabolic disorder? YES NO Has your doctor ever said that you have raised cholesterol? YES NO Do you have or have you ever suffered from a heart condition? YES NO Have you ever felt pain in your chest when you do physical activity? YES NO Is your doctor currently prescribing you drugs or medication? YES NO Have you ever suffered from shortness of breath at rest or with mild exercise? YES NO Is there any history of Coronary heart disease within your family? YES NO Do you ever feel faint, have spells of dizziness or have ever lost consciousness? YES NO Do you currently drink more than the average amount of alcohol per week? (21 units for men, 14 for women. 1 unit = 1⁄2 pint of beer/cider or small glass of wine) YES NO Do you currently smoke? YES NO Are you, or is there any possibility that you may be pregnant YES NO Do you know of any other reason why you should not participate in a programme of physical activity? YES NO Any further information you think we should know: Send
