PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PARQ)
Name:
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Surname:
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Phone:
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Email:
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Confirm Email:
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Date of Birth:
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Gender:
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Height if known:
Weight if known:
Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration. e.g. Nil, light, moderate or vigorous and number of hours per week?:
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Current eating regime e.g. Normal, fasting, other eating plan?:
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Do you have a specific health and fitness goal you wish to achieve?:
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Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or that you should only do physical activity recommended by a doctor?:
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NO
YES
Do you feel pain in your chest when you do physical activity?:
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NO
YES
In the past month, have you had chest pain when you were not doing physical activity?:
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NO
YES
Do you lose your balance because of dizziness or do you ever lose consciousness?:
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NO
YES
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?:
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NO
YES
Do you have a diagnosed illness that could be made worse by physical activity?:
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NO
YES
Is your doctor currently prescribing medication for your blood pressure or heart condition?:
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NO
YES
Do you know of any other reason why you should not do physical activity?:
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NO
YES
Is there anything else you would like to add that would help us to train you safely? E.g. other conditions not mentioned above and name any medications you take.:
FITNESS PARTICIPATION AGREEMENT - I have voluntarily chosen to participate in this FREE fitness session with PHAT Disruption. I have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent me from participating. I acknowledge that participation is at my own pace and comfort level and that I may discontinue my participation at any time. Furthermore, I agree to self-determine my exertion through good judgement and to discontinue any activity that exceeds my personal limitations. I understand that by signing this agreement that I hereby waive and release PHAT Disruption, its Board Members, staff, and all relevant employees in any way from liabilities or demands as a result of injury, loss, death or adverse health conditions as a result of my participation. I affirm that I have read and understand this document and I wish to participate in fitness activities. TICKING I AGREE IS YOUR ACCEPTANCE OF THIS AGREEMENT. PLEASE NOTE IF YOU HAVE SELECTED YES TO ANY OF THE MEDICAL QUESTIONS ABOVE, PLEASE SEEK GUIDANCE FROM AN APPROPRIATE ALLIED HEALTH PROFESSIONAL OR MEDICAL PRACTITIONER PRIOR TO UNDERTAKING EXERCISE. THE PHAT Disruption COACHES MAY ALSO CONTACT YOU IN REGARD TO YOUR ANSWERS ABOVE:
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I AGREE
Would you like to subscribe to our weekly Chew the PHAT Weekly newsletter to stay up to date on what we are offering, recipes, educational articles and workouts you can do at home? We would never use your email to spam you with loads of junk. You can opt out of receiving our newsletters at any time:
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YES
NO
I AM ALREADY SUBSCRIBED
FULL NAME OF PARTICIPANT:
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IF PARTICIPANT UNDER 18 YEARS OF AGE, ENTER FULL NAME OF PARENT/GUARDIAN ACCEPTING THIS AGREEMENT ON THEIR BEHALF:
SIGNED ON THIS DAY:
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