HEALTH RISK FACTORS (PAR-Q)

AIM: To identify individuals with known disease, and/or signs or symptoms of disease, who may be at a higher risk of an adverse event due to exercise. An adverse event refers to an unexpected event that occurs as a consequence of an exercise session, resulting in ill health, physical harm or death to an individual.

Please complete the questions below. Should you have any questions about the screening form please contact me for clarification.

First name

Last name

Date of Birth

Month

Day

Year

Gender

Has your doctor ever said that you have a heart condition or have you ever suffered a stroke?

Yes

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity or exercise?

Yes

Do you ever feel faint, dizzy or lose balance during physical activity or exercise?

Yes

Have you had an asthma attack requiring immediate medical attention over the last 12 months?

Yes

If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the past 3 months?

Yes

Do you have any other serious health conditions that require special consideration for you to exercise?

Yes

IF YOU ANSWERED ‘YES’ to any of the 6 questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.

I confirm that I have permission to exercise