PARQ – Physical Activity Readiness Questionnaire & Safety Agreement

Keep Well Health Check & Exercise Readiness Form

Please complete this short form before joining Keep Well exercise sessions.

Questions or need help completing this form? Contact Coach Ced
Telephone: 07932 541 546

1. Your Details

Full Name Date of Birth Your Phone Number Email Address Emergency Contact Name Relationship to You Emergency Contact Telephone Number

2. Health Questions

Has a doctor advised that you should only exercise under medical supervision?

Yes No

Do you experience chest pain during physical activity?

Yes No

Have you experienced chest pain while at rest during the last month?

Yes No

Do you experience dizziness, fainting or significant balance problems?

Yes No

Do you have a bone, joint, knee, hip or back problem that could be affected by exercise?

Yes No

Are you taking medication for blood pressure, a heart condition, diabetes or dizziness?

Yes No

Is there any other health reason why exercise may not be suitable for you today?

Yes No

Please give details of any “Yes” answers or anything else you think your coach should know.

3. Safety Agreement

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that I am responsible for exercising within my own abilities and limits and will tell my coach if I feel unwell, uncomfortable or unable to continue.

If your health circumstances change, please let your coach know before taking part in another session.

4. Declaration & Signature

By typing your name below, you confirm that the information supplied on this form is correct to the best of your knowledge.

Type Your Full Name Date Completed

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PARQ – Physical Activity Readiness Questionnaire & Safety Agreement
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