Physical Activity Readiness Questionnaire

Physical Activity Readiness Questionnaire

This form should be completed before your first class, and then resubmitted annually, or following any changes to your health. If you are joining remote classes on Zoom you must submit BOTH forms.

Please read the questions and tick the relevant boxes.

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Name *

Email *

Email

Confirm Email

Has your doctor ever said that you have a heart condition and recommended only medically supervised activity? *

• YES
• NO

Do you have chest pain brought on by physical activity? *

• YES
• NO

Have you developed chest pain in the last month? *

• YES
• NO

Do you tend to lose consciousness or fall over as a result of dizziness? *

• YES
• NO

Do you have a bone or joint problem that could be aggravated by the proposed physical activity? *

• YES
• NO

Has your doctor ever recommended medication for your blood pressure or a heart condition? *

• YES
• NO

Are you aware, through your own experience, or from a doctor’s advice, of any other physical reason why you should not exercise without medical supervision? *

• YES
• NO

If you have answered ‘yes’ to any of the questions above, you must agree to the following statements: I acknowledge that I have either been given my doctor’s permission to participate, or that I have decided to participate in the activity without the approval of my doctor and do hereby assume all responsibility for my participation and activities. I understand that I am responsible for monitoring my own condition throughout the exercise programme and that should any unusual symptom occur I will cease my participation and inform the instructor of the symptoms.

• AGREE
• DISAGREE

I confirm that to the best of my knowledge all the information on this form is correct. *

• YES
• NO

Submit

Additional Questions for online sessions

It is not always possible for the instructor to see you during the session, so it is your responsibility to take necessary precautions to prevent injury. You must agree to the following statements to participate.

• I will keep the exercise area clear and clean, particularly checking for trip hazards.
• I will ensure the floor and footwear create a non slip surface to move on.
• In the case of a fall or emergency there will always be a responsible person nearby to give assistance. Or, if you are alone, you will take steps to ensure you can contact a responsible person in an emergency. This should be in the form of a panic button or similar device with fall detector. If you rely on a phone for emergency contact you should be aware that you may not be able to use the phone in an injury situation, and you acknowledge that you participate entirely at your own risk.

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I have read and agree to the above statements *

• AGREE
• DISAGREE

Name *

Submit