Hoops Rock Pre-Activity Readiness Questionnaire (PAR-Q)

The information contained within this form will help us agree whether you are safe to train or not. If there is any doubt regarding your fitness to train you should consult your GP.

Note: this information will be kept confidentially and only accessed by Hoops Rock instructors.Please write directly into the form – do not worry about the format changing as you do so.

Health related questions:

Please tick youranswer YES or NO to the following:YESNO

Q1. Has your doctor ever said that you have a heart condition?______

Q2. Do you have pains in your chest when performing physical activity?______

Q3. Have you had chest pain when you were not doing physical activity?______

Q4. Do you lose your balance due to dizziness,or ever lose consciousness?______

Q5. Is there a history of coronary disease in your immediate family?______

Q6. Do you suffer from high or low blood pressure?______

Q7. Do you suffer from high cholesterol______

Q8. Are you pregnant now or have you given birth within the last 6 months?______

Q9. Have you had surgery recently?______

If you have marked YES to any of the above, please elaborate below:

______

______

Q10. Do you have any chronic illness or physical limitations such as Asthma, diabetes? YES/NO

Please specify ______

Q11. Do you have any injuries, bone/joint or orthopedic problems such as bursitis, bad knees, back, shoulder, wrist or neck issues? YES/ NO Please specify______

Q12. Do you take any medications, either prescription or non-prescription regularly? YES/ NO

What is the medication for?______

How does this medication affect your ability to exercise or achieve your fitness goals?

Q13. Do you know of any other factor which may affect your ability to participate in physical activity?

Please specify______YES/ NO

Q9. If there is any other information that you would like us to know please add this here

______

If you answered YES to one or more questions:

Talk to your doctor either in person or by phone before you start becoming more physically active and/or taking a fitness appraisal. Tell your doctor what questions you answered yes to on this form.

You may still be able to do any activity you want as long as you start slowly and build up gradually or it may be that you need to restrict your activities to those which are safe for you.

Emergency Contact:

Please provide the name and number of someone who we can call in the event of an emergency:

Name:Number:

I confirm I have read and understood this PAR-Q and have completed it to the best of my knowledge:

Name: Date:

Signature: