Physical Activity Readiness Questionnaire

Personal Details

First name

Last name

Email

Phone

Date of Birth

Emergency Contact

Emergency Contact Name

Emergency Contact Phone number

Health Conditions

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

No

Do you feel pain in your chest when you do physical activity?

Yes

No

In the past month, have you had chest pain when you were not doing physical activity?

Yes

No

Do you lose balance because of dizziness or do you ever lose consciousness?

Yes

No

Do you have a bone or joint problem (for instance, back, knee or hip) that could be made worse by a change in your physical activity?

Yes

No

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes

No

Have you been diagnosed with a neurological condition?

Yes

No

Do you know of any other reason you should not do physical activity?

Yes

No

If you have answered yes to any of the above, please provide details here. Otherwise, write "N/A"

Please provide details of past major operations. Otherwise, write "N/A"

If you answered YES to one or more of the above questions:

You should consult with your doctor to clarify that it is save for you to become physically active at this current time and in your current state of health.

Please provide details of any other physical fitness programmes you are following or have followed in the past

Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the health condition questions. It is your responsibility to inform us of any changes to your medical condition.

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.