PAR-Q

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PAR-Q

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Join In
Contact
PAR-Q

Limpsfield Fitness PAR-Q form

Please complete this form to take part in any of our classes.

Privacy Statement:

The personal information collected in this form will only be used for the purposes of contacting you regarding your enquiry, informing your programme and providing medical clearance in order for you to take part in an exercise programme. This information will not be shared with any third parties outside of Limpsfield Fitness.

If you have any queries, wish to update your information or do not wish to disclose specific details then please contact jon@limpsfieldfitness.co.uk.

Your Details

First name(*)

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Last name(*)

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Email Address(*)

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Telephone Number(*)

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Gender(*)

Female
Male
Other Invalid Input

Date of Birth(*)

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Height (cm)

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Weight (kg)

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Your Goals

Please describe your current activity levels(*)

Sedentary (little or no exercise):
Lightly active (exercise 1–2 days/week)
Moderately active (exercise 3–5 days/week)
Active (exercise 6–7 days/week)
Very active (hard exercise 6–7 days/week) Invalid Input

Please provide a brief outline of your goals

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Emergency Contact

Emergency Contact Name & Relation(*)

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Emergency Contact Number(*)

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Permissions

Click here to opt out of granting Limpsfield Fitness rights to use your image for marketing material. This might include (but it not limited to), the right to use your image in online publicity and social media. Also click below if you would prefer not to be added to the Limpsfield Fitness mailing list where we will update of upcoming events and new classes.

I’d prefer not to have my image used for marketing purposes.
I’d prefer to not be added to the Limpsfield Fitness mailing list. Invalid Input

Physical Activity Readiness Questionnaire

If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with you doctors before you significantly change your physical activity patterns.
Common sense is your best guide when answering these questions.
Please read each question carefully and answer each one honestly.

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 Invalid Input

Do you feel pain in your chest when performing physical activity?(*)

Yes
No Invalid Input

Have you experienced chest pain when NOT performing physical activity in the last month?(*)

Yes
No Invalid Input

Do you lose balance because of dizziness or have you lost consciousness recently?(*)

Yes
No Invalid Input

Do you have any bone or joint problems such as arthritis, which could be aggravated through physical activity?(*)

Yes
No Invalid Input

Is your doctor currently prescribing you medication for high blood pressure or a heart condition? If YES please use the box below to describe which medication.(*)

Yes
No Invalid Input

Blood Pressure Details

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Have you had an operation in the last 12 months? If YES please use the box below to provide details.(*)

Yes
No Invalid Input

Operation Details

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Please provide any further details that may affect your ability to perform exercise as part of a program.

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If you answered NO to all the PAR-Q questions you can be reasonably sure that you can exercise safely and are at low risk of having any medical complications from exercise. It is still important to start slowing and increase gradually.

If you answered YES to one or more questions, are older than age 40 and have been inactive or are concerned about your health, consult a doctor before taking a fitness test or substantially increasing your physical activity. You should ask for medical clearance along with information about specific exercise limitations you may have.
In most cases you will still be able to do any type of activity you want as long as you adhere to some guidelines.
When to delay the start of an exercise program:

If you are not feeling well because of temporary illness, such as a cold or fever wait until you feel better to begin exercising
If you are or may be pregnant, talk with your doctor before you start becoming more active.

Declaration

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise and my participation involves a risk of injury.

If answered yes to any questions in the previous section: (PLEASE NOTE: This clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the previous questions in section 2)(*)

I have sought medical advice and my GP has agreed that I may exercise.
N/A - Did not select YES to any of the previous questions Invalid Input

Signed (full name) * taken as digital signature(*)

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Date(*)

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Limpsfield Fitness
The fun way
to fitness

Physical Activity Readiness Questionnaire

Find Us

Limpsfield Fitness
The Pavilion
Glebe Meadow
Limpsfield
Surrey
RH8 0DG

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Telephone: 07772 876 980
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