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EST 2005
PAR Q
To register to our gym please fill out the following medical form
First name
Date of Birth
Surname
Phone
Email address
Emergency contact name
Emergency contact number
Has your doctor advised that you should not participate in physical activity or exercise?
No
Yes
Are you pregnant or post natal?
No
Yes
Do you suffer from asthma or breathing difficulties?
No
Yes
Have you been in hospital in the last 3 years?
No
Yes
Are you taking any medication?
No
Yes
Do you suffer from diabetes or epilepsy?
No
Yes
Has your doctor ever said that you have a heart condition and that you should only participate in physical activity recommended by a doctor?
No
Yes
Do you feel pain in your chesst when you do physical activity?
No
Yes
Do you lose your balance because of dizziness or do you ever lose conciousness?
No
Yes
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
No
Yes
Is your doctor prescribing drugs for your blood pressure or heart condition?
No
Yes
Do you know of any other reason why you shouldn't participate in physical activity?
No
Yes
Do you require an induction?
No
Yes
If you answered YES to any of the above questions, please provide more information:
Initials
Today's date
I declare that the info I’ve provided is accurate & complete
Your signature
Clear
Submit
Thanks for submitting!
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