Dawn Chambers Fitness

Physical Activity Readiness Questionnaire (PARQ)

All clients are required to complete a PAR-Q before commencing any exercise programme with Dawn Chambers Fitness. All information will be held in the strictest of confidence.

If you are between the ages of 16 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your activity patterns. If you are over 69 and are not used to being very active, please check with your doctor before increasing your activity patterns. Dawn Chambers Fitness may require a letter of ‘medical clearance’ from your GP. Please be aware that your GP may charge you for this.

It is the responsibility of the client to maintain the accuracy of their enrolment form and notify Dawn Chambers Fitness immediately if there are any changes to their health / contact details / emergency contact details. This PAR-Q becomes invalid if you fail to notify Dawn Chambers Fitness of any medical changes which might result in you answering Yes to any of these questions.

New PAR-Q's can be submitted at any time via this online form. Common sense is your best guide when answering these questions. Please read carefully and answer each one honestly.

Relating to exercise

My (Dawn Chambers Fitness) commitment to you;

1) I will respect your personal decisions, and allow you to make your own decisions about what exercise you can carry out. However, I ask you not to exercise beyond what you consider to be your own abilities.

2) I will take reasonable steps to make sure that the equipment and facilities are clean and safe for you to use and enjoy for the normal purpose they were intended for. Bear in mind that I am not able to clean or inspect equipment and facilities after each use.

3) I am committed to my continuing professional development and to maintain my qualifications to fitness industry standards.

4) If you tell me you have a disability which puts you at a substantial disadvantage in accessing the equipment and facilities, I will consider what adjustments, if any, are reasonable for me to make.

First name

Last name

Phone

Emergency Contact Name

Emergency Contact Telephone Number

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

Yes

Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

Yes

Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise)

Yes

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

Yes

Are you currently taking prescribed medications for a chronic medical condition?

Yes

Have you had a bone, joint, or soft tissue (muscle, ligament, or tendon) problem in the past 12 months that could worsen with physical activity? Answer NO if this does not limit your current ability to be active.

Yes

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

Yes

Has your doctor ever said that you should only do medically supervised physical activity?

Yes

Are you pregnant or have recently had a baby?

Yes

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

Yes

Are you currently suffering from any signs or symptoms of long Covid i.e. chronic fatigue?

Yes

Please provide details of any other relevant diagnoses or treatments

Did you answer Yes to any of the questions above?

Yes

I confirm I will NOT attend class if I am feeling unwell or if I have coronavirus symptoms (a persistent cough, high temperature, loss of taste and smell)

By submitting this form I confirm that 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. I willingly participate in the practical exercises at my own risk.

I have no physical restrictions, disabilities or any predisposition to sickness or injury that may be aggravated or adversely affected as a result of my participation. I take full responsibility for any injury, loss or damage to my person or property that may arise directly or indirectly from my participation in the exercises. I will not seek to penalise, prosecute or claim compensation from the Dawn Chambers Fitness for any injury, loss or damage.

I understand that the information on this form is valid for a maximum of twelve months from the date of submission and becomes invalid if my circumstances change. All information provided is confidential and is stored securely and used solely by Dawn Chambers Fitness. Any personal data provided will be held for as long as is necessary having regard to the purpose for which it was collected and in accordance with all applicable UK laws.

Please electronically sign either by adding your signature or by typing your full name.

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