PAR-Q

Medical History

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

Yes
No

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

Yes
No

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

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness?*

Yes
No

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

Yes
No

Do you suffer from high/low blood pressure, heart conditions or diabetes?*

Yes
No

If yes, is your doctor currently prescribing medication for these conditions?

Yes
No

Do you know of any other reason why you should not do physical activity?*

Yes
No

If yes, please comment:

Are you currently or in the past 3 months being prescribed any medication?*

Yes
No

YES to one or more questions:

You should consult 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.

NO to all questions:

It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.

Exercise Habits and Personal Details

Do you exercise?

Yes
No

If yes, how many times a week?

How long do you exercise for?

What type of exercise (aerobic, resistance etc?)

Other activity:

Height

Weight

Date of birth:

I have read, understood and completed this questionnaire.*

Yes

All questions have been answered to the best of my knowledge.*

Yes

I confirm that I wish to participate in activities that may include aerobic exercise and stretching and realise that my participation involves a risk of injury. I hereby confirm I am voluntarily engaging in an acceptable level of exercise for me.*

Yes

I consent to receiving course updates etc. via email*

Yes
No

How did you hear about Coast Road Runners?

Word of Mouth
Internet Search
Facebook
Instagram
Newspaper
Poster/Flyer
Other

Note: this physical activity 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 preceding medical health questions.

Name*

Date

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PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

Medical History

Exercise Habits and Personal Details

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