The Tenth Yard Southend

    Physical Activity Readiness Questionnaire (PAR-Q)

    Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise?

    Do you have high blood pressure?

    Do you have low blood pressure?

    Do you have diabetes mellitus or any other metabolic disease?

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

    Has your doctor ever said you have raised cholesterol (serum level above 6.2mmol/L)?

    Have you ever felt pain in your chest when you do physical activity?

    Is your doctor currently prescribing you drugs or medication?

    Have you ever suffered from unusual shortness of breath at rest or with mild exertion?

    Is there any history of coronary heart disease in your family?

    Do you often feel faint, have spells of sever dizziness or have lost consciousness?

    Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women?

    Do you currently smoke?

    Are you, or is there any possibility that you might be pregnant?

    Do you know of any reason why you should not participate in a program of physical activity?

    If you answered 'yes' to one or more questions:

    If you have not recently done so, consult with your doctor by telephone or in person before increasing your physical activity and/or taking a fitness appraisal. Tell your doctor which questions you answered "yes'' to on the PAR-Q or present your PAR-Q copy. After medical evaluation, seek advice from your doctor as to your suitability for:

    - Unrestricted physical activity starting off easily and progressiong gradually and,

    - Restricted or supervised activity to meet your specific needs, at least on an initial basis

    No to all questions:

    If you answered your PAR-Q accurately, you have reasonable assurance of your present suitability to take part in physical gym activity.

    Assumption of risk:

    I hereby state that I have read, understood and answered honestly the questions of the PAR-Q. I also state I wish to participate in activites that may include aerobic exercise, resistance training and stretching. I realise that my participation in these activites involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise.

    Please select todays date

    Please enter your signature in the box below;

    Lifestyle Questions

    Gender

    Date of Birth

    Occupation

    Current weight (KG/Lbs)

    Current Height (Feet/Cm)

    What is your main goal? Be as specific as possible.

    Do you have any experience in training? If so, please state.

    How many days a week can you commit to training?

    What time of day will you mainly be able to train? Rough times are fine.

    Do you have any injuries that may restrict or stop you performing certain exercises? If yes, please state.

    What environment do you have available to train in?

    Is your job physically demanding?

    On a scale of 1 to 10, 1 being the worst, 10 being the best, how would you rate your current eating habits?

    Do you have any food allergies or dietary requirements? If yes, please state.

    Your typical Breakfast...

    Your typical Lunch...

    Your typical Dinner...

    E-mail

    Mark@TheTenthYard.co.uk

    Phone number

    07900 456 063