Player PAR-Q – Dink Brighton

Name

First

Last

Name that or

Date of Birth

Q1: Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes
No

Q2: Do you feel pain in your chest when you do physical activity?

Yes
No

Q3: In the past month, have you had a chest pain when you were not doing physical activity?

Yes
No

Q4: Do you lose balance because of dizziness or do you ever lose consciousness?

Yes
No

Q5: Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity?

Yes
No

Q6: Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes
No

Q7: Do you know of any other reason why you should not take part in physical activity?

Yes (Please add further information below)
No

Q7 Additional Information:

If you answered YES to one or more questions: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health. If you answered NO to one or more questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levels.

My understanding & accuracy of completion

I agree

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.

Signature (Print Name)

Today's Date

Checkboxes (copy)

I agree

Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise.

Signature (Print Name)