Physical Activity Readiness Questionaire – Dragon Fitness

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PARQ

P-A-R-Q

Physical Activity Readiness Questionnaire

Name

Email Address

Contact Number

Emergency Name and Number

DOB

Do you have a heart condition, high blood pressure or circulatory problems?

Yes No

Do you experience chest pain when exercising or at rest?

Yes No

Do you ever suffer from dizzy spells whilst execising?

Yes No

Do you have any back or joint conditions that can be exacerbated by exercise?

Yes No

Do you have Asthma

Yes No

Have you had any surgery in the past year that may affect your physical activity?

Yes No

Are you aware of any other conditions that may affect your ability to exercise?

Yes No

Are you taking any medications?

Yes No

Are you pregnant or have you given birth in the ast six weeks?

Yes No

If you have answered YES to any of the questions above please provide details

Please comfirm you are fit and well to participate in physical activity

Yes No