Physical Activity Readiness Questionnaire (PAR-Q)

CAA/MBT are collecting this information, to make sure that you are fit and well so that you may take part in all physical activity’s held at the CAA/MBT.

All student/members personal information will be kept in a secure location under lock and key.

Should a student/member leave the CAA/MBT ALL documentation relating to the individual student/member will be destroyed.

If you have questions, or would like more information, please leave your name and contact information.

Name
DOB
Address
Postcode
Email
Phone
Next of Kin
Phone
What health goals would you like to achieve in the next 3 months?
Name 3 things you could do in order to improve your health?
What are your main reasons for starting a fitness programme
How would you describe your general health and fitness
Have you ever done any structured exercise?
If ?Yes' what did you do?
What type of exercise do you enjoy the most?
What type of exercise do you dislike the most?
What would you say are the main barriers preventing you from exercising?
On a scale of 1-10 (with 1 being poor and 10 being excellent) how would you assess the quality of your eating habits?
Would you like any help or advice in changing the quality of your eating habits
Do you follow any particular diet or eating patterns?
Do you drink alcohol
Do you smoke
If you answered ?Yes' would you like help or advice to change these habits?
Have you had a major illness or injury in the last 5 years
If ?Yes' please give details
Are you receiving treatment for any diagnosed medical condition?
Are you receiving treatment for any diagnosed medical condition?
Are you taking any prescription medication?
If ?Yes' please give details
Ever get unusually short of breath with very light exertion?
Ever have pain pressure heaviness or tightness in the chest area?
Regularly have unexplained pain in the abdomen shoulder or arms?
Ever have severe dizzy spells or episodes of fainting?
Regularly get lower leg pain during walking that is relieved by rest?
Ever experience palpitations or irregular heartbeats?
Are you currently pregnant or have given birth in the last 6 months?
Please indicate any other health problems you suffer from which you have not already mentioned.
PRINT NAME
Are you the parent/guardian of the above named person
SIGNATURE (Type Initials)
DATE
Do not enter anything in this field: