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PAR - Q

Gender
Female
Male
Prefer not to say
Non Binary
Other
Do you consider yourself to have a disability?
Yes
No

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE & YOU (PAR Q)


Being more active is very safe for most people however some people should check with their doctor before they start becoming much more physically active. PAR Q is designed to identify the smaller number of adults for whom physical activity might be inappropriate or those who should seek medical advice concerning the type of activity most suitable for them. If you are over 69 and you are not used to being very active, please check with your doctor. Common sense is the best guide when you answer these questions.


Please read the questions carefully and answer each one honestly. YES or NO – If YES please give further details / dates in the box at the bottom of this form etc.

Has your doctor ever said that you have any kind of heart condition/angina?
Yes
No
Did a doctor recommended you start participating in this type of exercise?
Yes
No
Do you feel pain in your chest when you do physical activity or have felt pain recently?
Yes
No
Is your doctor currently prescribing drugs (ie water pills) for your blood pressure or heart condition?
Yes
No
Do you have low/ high blood pressure or cholesterol? If so which? Are you on medication for this?
Yes
No
Do you lose balance because of dizziness or do you often feel faint?
Yes
No
Have you been diagnosed with any kind of vertigo or problems with the inner ear?
Yes
No
Do you suffer from epilepsy?
Yes
No
Do you suffer from diabetes? If so; Is this controlled by diet / tablets/ insulin?
Yes
No
Do you suffer from asthma? Do you need inhalers?
Yes
No
Do you suffer from shortness of breath at rest?
Yes
No
Have you been in hospital or had any operations/ surgery recently? Hysterectomy/ Prolapse etc?
Yes
No
Are you or is there any possibility you could you be pregnant?
Yes
No
Do you suffer from any form of blood disorder?
Yes
No
Are you currently or in the last 12 months received any treatment for any cancer related illness? Chemotherapy? Radiotherapy?
Yes
No
Do you suffer from cramp? Legs/ feet
Yes
No
Are you allergic to or ever had a reaction to latex?
Yes
No
Have you been diagnosed with Osteopenia or Osteoporosis? Are you on any medication for this?
Yes
No
Have you had a dexa scan and how recent? Which part of the body is affected? Hip/ Spine?
Yes
No
Do you know your bone mineral density score?
Yes
No
Do you suffer from any bone or joint problem which causes a mobility problem or reduced movement in a joint?
Yes
No
Have you had any joint replacements – Hip/ Knees? If so; How long ago? Have you had any problems with the joint since surgery?
Yes
No
Have you been diagnosed with hypermobility? If so; has a GP or physio given you a score indicating how hypermobile you are?
Yes
No
Have you ever suffered from or have a frozen shoulder or any shoulder injury? How long ago?
Yes
No
Are you fully recovered? If frozen shoulder; which phase are you currently in? Have you had treatment?
Yes
No
Been referred to a physio?
Yes
No
Have you ever suffered from any tears or injury to any ligaments? Give further details.
Yes
No
Have you ever suffered from or have golfers elbow/ tennis elbow? Which one?
Yes
No
Do you suffer from Rheumatoid or Osteo - arthritis? Which? When were you diagnosed?
Yes
No
Are you on medication? Do you suffer with flare ups? How often?
Yes
No
Do you suffer from any kind of back pain? Which part of back – Upper/ Middle/ Lower?
Yes
No
Is this non-specific back pain which you have treated yourself?
Yes
No
Have you had a diagnosis from a doctor/GP/Physio for a specific back problem or pain? Ie. Trapped Nerve /Herniated Disk/ Spinal Stenosis/ Spondylolisthesis/ Piriformis Syndrome?
Yes
No
If disk problems – which section/vertebra of the spine is affected?
Yes
No
Are there any movements or activities which aggravate or make the sciatica worse?
Yes
No
Have you been referred to a physio/osteopath for your back condition? How recent? Are you still seeing them?
Yes
No
Have you had surgery or on a waiting list for any surgery on your back?
Yes
No
Do you take any medication on a regular basis for any condition which is NOT listed above?
Yes
No
Have you had a positive test for Covid 19? If so: How long ago? Are you fully recovered?
Yes
No
Have you been diagnosed with Long covid? Are you still receiving treatment?
Yes
No
If so; What treatment/ medication are you receiving and how often? How long ago were you diagnosed?
Yes
No

If you have answered NO honestly to all the questions then you can be reasonably sure that you can start to become more physically active - begin slowly and build up gradually. This is the safest and easiest way to go. If you are not feeling well due to a temporary cold or fever then you should avoid exercising until you feel better. If your health changes so that you would then answer YES to any of the above questions then please advise your fitness instructor immediately. If you have answered YES to any questions you must talk to your doctor by phone or in person before you start becoming more physically active and obtain their advice and if necessary written proof of this may be needed.


I have read, understood and completed the questionnaire. I confirm that I have sought advice from my GP or specialist consultant if applicable before commencing this exercise programme and have revealed, to the best of my knowledge, anything which may affect me as a result of exercise. If I choose not to consult my GP, I do so at my own risk and

participating in any physically activity I am unable to hold any person liable for any injury or even possible death. Some classes may involve using equipment such as mats, bands, hand weights or balls. If you prefer not use these then please advise the instructor. You are asked to use the equipment responsibly and as per the instructors instructions.


Photos may be taken during the class to use for future advertising/marketing of the class, if you prefer not to be shown

in these then please advise the instructor.


All data will be held confidentially in line with the current data protection act. By completing this form you agree for your information to be shared with those involved in session delivery and your demographic information will be shared with our funder Places Leisure.

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