PARQ - Physical Activity Readiness Questionnaire & Safety Agreement

1. Your Details

Full Name Date of Birth Phone Number Email Address Emergency Contact

Has a doctor advised supervised exercise only?

Yes No

Chest pain during activity?

Yes No

Chest pain at rest in last month?

Yes No

Dizziness / fainting / balance issues?

Yes No

Bone / joint / knee / hip / back issue?

Yes No

Medication for BP / heart / diabetes / dizziness?

Yes No

Any other reason exercise may not suit today?

Yes No

Health Notes

I confirm the above details are accurate and I will exercise within my own limits.

Type Full Name Date