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PAR-Q FORM

Has your doctor ever indicated that you have a heart condition?
YES
NO
Has your doctor every indicated that you have high blood pressure?
YES
NO
Do you feel pain in your chest at rest, during your daily normal activities OR when you do physical activities?
YES
NO
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
YES
NO
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
YES
NO
Are you currently taking prescribed medications for chronic medical conditions?
YES
NO

If you answered NO or N/A to all of the questions above, you are cleared for physical activity. If you answered yes to one or more of the questions, there will be another form to fill in before you will be cleared to exercise.

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MEDICAL HISTORY REVIEW FORM

Title:
Miss
Ms
Mrs
Mr
Date of Birth:
Day
Month
Year

In the event of an emergency, please contact:

Doctors Details

Health Questionnaire

Past and Present Health Questions

Are you currently receiving treatment from a doctor, hospital or clinic?
Yes
No
Are you taking any prescribed medicines? (This includes tablets, inhalers, injections, contraceptives and ointments)
Yes
No
Are you taking any self-prescribed medicines/drugs? (This includes pain killers or recreational drugs)
Yes
No
Do you carry a medical warning card or bracelet?
Yes
No
Are you pregnant or possibly pregnant?
Yes
No
Do you suffer with bronchitis, asthma or any other chest conditions?
Yes
No
Do you have epilepsy or any other neurological disorders?
Yes
No
Do you have high or low blood pressure?
Yes
No
Do you have any heart problems or have you had any heart procedures?
Yes
No
Do you have diabetes?
Yes
No
Do you have a bone or joint disease? (Arthritis, osteoporosis etc.)
Yes
No
Do you suffer from any mental health conditions? (Bipolar, depression, schizophrenia, dementia etc.)
Yes
No
How would you rate your stress levels over the last 6 months?
High
Moderate
Low
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

MEDICAL HISTORY REVIEW FORM

Title:
Miss
Ms
Mrs
Mr
Date of Birth:
Day
Month
Year

In the event of an emergency, please contact:

Doctors Details

Health Questionnaire

Past and Present Health Questions

Are you currently receiving treatment from a doctor, hospital or clinic?
Yes
No
Are you taking any prescribed medicines? (This includes tablets, inhalers, injections, contraceptives and ointments)
Yes
No
Are you taking any self-prescribed medicines/drugs? (This includes pain killers or recreational drugs)
Yes
No
Do you carry a medical warning card or bracelet?
Yes
No
Are you pregnant or possibly pregnant?
Yes
No
Do you suffer with bronchitis, asthma or any other chest conditions?
Yes
No
Do you have epilepsy or any other neurological disorders?
Yes
No
Do you have high or low blood pressure?
Yes
No
Do you have any heart problems or have you had any heart procedures?
Yes
No
Do you have diabetes?
Yes
No
Do you have a bone or joint disease? (Arthritis, osteoporosis etc.)
Yes
No
Do you suffer from any mental health conditions? (Bipolar, depression, schizophrenia, dementia etc.)
Yes
No
How would you rate your stress levels over the last 6 months?
High
Moderate
Low
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
CONTACT US

PHOENIX AVENUE FEATHERSTONE, WF7 6EP

A12 PERSONAL TRAINING

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