PAR-Q Health Questionnaire Please fill in our the Health Questionnaire Form before attending you’re first classIf you are currently pregnant, please use this form instead - Click Here Email * Name * First Name Last Name 1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? * Yes No 2. Do you feel pain in your chest when you perform physical activity? * Yes No 3. In the past month, have you had chest pain when you were not performing any physical activity? * Yes No 4. Do you lose your balance because of dizziness, or do you ever lose consciousness? * Yes No 5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? * Yes No 6. Are you currently taking any medication we should be aware of? * Yes No 7. Do you know of any other reason why you should not engage in physical activity? * Yes No 8. Have you ever had any injuries, surgeries, or medical procedures (e.g., back surgery, joint replacement)? * Yes No 9. Are you currently experiencing any pain or discomfort? * Yes No 10. Do you have any other medical conditions not mentioned (e.g. Asthma, Diabetes, Arthritis, Epilepsy, Hernia, Circulation problems)? * Yes No 11. Are you currently pregnant or have you given birth within the last six months? * Yes No If you answered YES to any of the questions above. Please give details below: Do you have any allergies? (if yes, please specify) Emergency Contact Details * First Name Last Name Emergency Contact Number * (###) ### #### * I confirm that I have completed the above questionnaire to the best of my ability and that I have provided accurate information regarding my current health status. I take it upon myself to discuss any changes in my health with my instructor. I understand that any exercise programme has certain risks. I understand that the degrees of risk depend on my health and physical fitness. I am voluntarily participating in the class, and will immediately discontinue any activity if I feel any symptoms of distress or discomfort, and will notify my instructor. Please print name and date electronically below. I Agree Name * First Name Last Name Date * MM DD YYYY Add me to the EMBA Monthly Newsletter Yes No Thank you for submitting your Health Questionnaire. We look forward to seeing you at the studio!
