PAR-Q 2 First NameLast NameAddressAddress Line 1Address Line 2CityCountyPost CodeMobile numberEmailOccupationDate of Birth – dd/mm/yyyyHow did you hear about us?Next of KinNext of Kin details: NameContact NumberAlternative Contact DetailsHealthcare DetailsHealthcare DetailsGP NameGP PractiseGP Phone NumberMedical HistoryYour Medical HistoryHave You Experienced Any of The Following Either Past or Present? Significant Heart Disease Significant Lung Disease Uncontrolled Type 1 Diabetes Uncontrolled Epileptic Fits/Seizures Dyspnoea (Difficult Breathing) Before Exertion Dizziness Headache Chest Pain Calf Pain or Swelling Dramatic Recent Weight Gain Sacrum or Sacroiliac Joint Pain Carpal Tunnel Syndrome/Wrist Pain Knee Pain Lower Back Pain Upper Back/Neck Pain Coccyx Damage or Pain Separation or Abdominal Muscles (Diastasis) Urinary/Faecal Incontinence Prolapse Piles Varicose VeinsAny Other Injuries Past or Present to be Aware of?Previous Exercise History & Regular Fitness or Recreational ActivitiesAny Medical History That You Feel Could Affect Your Ability to Exercise?Are You Taking Any Medications?Other Medical History Background and Other Health Practitioners Visited What Are Your Goals for Participating in Exercise?Please Provide Any Further Information You Can on Your Previous Pregnancy and Postnatal History, Possible Complications from Your Medical Background or Other Health Practitioners VisitedThank you Thank you for taking time to complete the PAR-Q carefully. This form has been emailed to [email protected] . Feel Free to get in touch if you have any questions or problems in completing this form. Send Details
