Name: Address: Postcode: Email: Mobile: Physical Activity Readiness Questionnaire (PAR-Q) If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Common sense is your best guide when answering these questions. Please read carefully and answer each one honestly: check YES or NO. 1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? Yes No 2. Do you feel pain in your chest when you do physical activity? Yes No 3. In the past month, have you had a chest pain when you were not doing physical activity? Yes No 4. Do you lose balance because of dizziness or do you ever lose consciousness? Yes No 5. Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity? Yes No 6. Is your doctor currently prescribing medication for your blood pressure or heart condition? Yes No 7. Do you know of any other reason why you should not do physical activity? Yes No If yes, please comment: YES to one or more questions You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health. NO to all questions It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levels. I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury. Signature Date Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise. Signature Date Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the 7 questions.