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PAR Q Form

Name

First Name

Last Name

Email Address

Contact Number

Emergency Contact Name

Emergency Contact Number

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor/physician?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

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

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in physical activity?

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Are you pregnant?

Are you 69 years or older?

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

I am aware that Samien Fitness is not responsible injury and/or death that may occur whilst using the facilities.

Do you require an Induction?

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