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The Movement

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- Amelia Customer
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Medical questionnaire [PAR-Q]
Person to contact in case of emergency*
Emergency Contact Number*
Questions
1. Has your doctor ever said that you have had a heart condition and that you should only do physical activity recommended by a doctor?*
- Yes
- No
Please explain
2. Do you feel pain in your chest when doing physical activity?*
- Yes
- No
Please explain
3. In the past month, have you had chest pain when you were doing physical activity?*
- Yes
- No
Please explain
4. Do you lose your balance because of dizziness or do you ever lose consciousness?*
- Yes
- No
Please explain
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?*
- Yes
- No
Please explain
6. Is your doctor currently prescribing drugs ( for example, water pills ) for your blood pressure or heart condition?*
- Yes
- No
Please explain
7. Do you know of any reason why you should not do physical activity?*
- Yes
- No
Please Explain
Agreement*
- I have read and understood the above information. If there are any changes in my circumstances above, I will inform the studio.
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Talk with your doctor BEFORE you start becoming much more physically active or BEFORE you undergo a fitness programme. Talk with your doctor about the Lift questionnaire and to which questions you answered YES. - You may be able to do any activity you want – as long as you start slowly and build up gradually. - Or, you may need to restrict your activities to those which are safe for you. - Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. - See reverse if you decide not to consult your doctor. If you answered NO honestly to all the questions: You can be reasonably sure that you can: - Start becoming much more physically active- begin slowly and build up gradually. This is the safest and easiest way to go. - We recommend you have a group orientation or personal training session to determine your basic fitness. Delay becoming much more active: - If you are feeling unwell because of a temporary illness such as a cold or fever- wait until you feel better. - If you are or may be pregnant – talk to your doctor before you start becoming more active. Please note: If your health changes so that you then answer YES to any of the above questions, before exercising tell an instructor. Ask whether you should change your physical activity plans. Waiver Claim: Although this questionnaire is designed to assist Lift when advising on individual exercise needs, members are reminded that Lift cannot be held responsible for the health of individual members and that it is the responsibility of all members to consult their doctor prior to commencing any exercise programme.

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ABOUT
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