Name * First Name Last Name Physical Activity Readiness Questionnaire (PAR-Q) Moderate or vigorous exercise is generally safe for most individuals when integrated into a regular program that begins at low intensity and gradually increases. However, certain individuals will require a medical evaluation and advice before starting, some may need to exercise under medical supervision, and others might only be able to engage in limited physical activity under medical supervision. ANSWER ALL QUESTIONS If you answered NO to one or more questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. If you answered YES to one or more questions: You should consult with your doctor to confirm that it is safe for you to become physically active prior to participating in any exercise program. Has Your Doctor Ever Said You Have Heart Disease, High Blood Pressure or Any Other Cardiovascular Problem? * Yes No Is There a History of Heart Disease in Your Closest Family (Below Age 55)? * Yes No Do You Ever Have pains in Your Heart and Chest, Especially Associated With Minimal Effort? * Yes No Do You Lose Your Balance Because of Dizziness or Do You Ever Lose Consciousness? * Yes No Do You Have a Bone or Joint Problem That Could Be Made Worse by a Change in Your Physical Activity? (Examples: Back, Hip or Knee) * Yes No Is Your Doctor Currently Prescribing Drugs for Your Blood Pressure or Heart Condition? * Yes No Are You Taking Drugs / Medication at the Moment or Recuperating From Recent Illness or Operation? * Yes No Are You Pregnant? * Yes No Are You Unaccustomed to Exercise and Aged Over 50, if a Woman or Over 40, if a Man? * Yes No Do You Know of Any Other Reason Why You Should Not Do Physical Activity? (e.g. Diabetes, Epilepsy) * Yes No If You Answered Yes to Any of the Above Questions Please Describe in More Detail as to Why You Answered “Yes” * I have read, understood and completed the questionnaire Terms & Conditions * Waiver: https://www.alfaactive.co.uk/waiver Privacy Policy: https://www.alfaactive.co.uk/privacy-policy I have read and agreed to the terms above Thank you!
