Physical Activity Readiness Questionnaire (PARQ)

Name

First Name

Last Name

Date of Birth

Phone Number

Do you have a bone or joint problem (eg shoulder, back, knee, hip, or foot) that could be made worse by a change in your physical activity? Please specify.

Past/current injuries:

Sports/Activities (times per week):

Has your doctor ever said you have a heart condition?

Do you feel pain in your chest when you are not doing physical activity?

Do you lose your balance because of dizziness or do you lose consciousness?

Is your doctor currently prescribing medication for your blood pressure or heart condition or type 2 diabetes?

Do you know of any other reason why you should not do physical activity?

If you have answered YES to one or more of the above questions, please talk to your doctor about this exercise programme and follow his/her advice. If you feel there is anything else I need to know, please use this space to tell me.

Disclaimer

Please note that I am not medically trained. Any information I give you is not, in any way, a replacement for any medical advice you may have received. You are totally responsible for your own health and safety both during and after the session. Results are not guaranteed. I am a fully qualified Restorative Exercise Specialist. I understand that my personal information will remain confidential and will be stored and processed in accordance with GDPR regulations. The Heart and Sole Movement privacy policy is available on www.heartandsolemovement.com. I have read, understood and accurately completed this questionnaire. I confirm that I am volutarily engaging in an acceptable level of exercise and I hereby declare that I will not hold Michelle Muldoon of Heart and Sole Movement responsible for injuries arising from this or any other future sessions.

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