PARQ - Personal Trainer Dublin

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

Yes
No

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

Yes
No

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

Yes
No

4. Do you lose your balance because of dizziness or do you ever lose consciousness?*

Yes
No

5. Do you have a bone or joint problem (e.g. back, knee or hip) that could be made worse by a change in your physical activity?**

Yes
No

6. Are you diabetic?*

Yes
No

7. Is your doctor currently prescribing medication for your blood pressure or a heart condition?*

Yes
No

8. Are you pregnant or have you been pregnant in the last 6 months?*

Yes
No

9. Are you currently taking any medication? If yes, what and for what reason?*

Yes
No

If you have answered Yes above to 9, please fill in information now:

10. Do you know of any other reason why you should not do physical activity?*

Yes
No

If you have answered Yes above to 10, or have any other concerns not covered already, please fill in information now:

Yes to one or more questions 1-4: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health. Yes to one or more questions 5-10: You can be reasonably sure that it is safe for you to participate in physical activity proved special consideration is given to the above, gradually building up from your current ability level. No to all questions: You can be reasonably sure that it is safe for you to participate in physical activity, gradually building up from your current ability level.

‘I have read, understood and accurately completed this questionnaire. I confirm that I am voluntary engaging in an acceptable level of exercise, and my participation involves a risk of injury.’*

Yes

Name*

First Last

Phone Number*

Email*

Dublin Postal Address*

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