PAR Q Form

Name*

First Last

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date of Birth*

Phone*

Email*

Pre-Induction Questionnaire

Before using the Woodlands Fitness Centre, it is necessary to establish your current health status. The questions below are designed to identify the small number of adults who should seek medical advice concerning the type of exercise most suitable for their needs.

Part 1

Please select YES/No for each question.

1. Has your doctor ever identified you having a heart condition and recommended only medically supervised activity?*

2. Do you have chest pain brought on by physical activity?*

3. Have you developed chest pain in the last month?*

4. Do you tend to lose consciousness or fall over as a result of dizziness?*

5. Do you have joint problems that could be aggravated by the proposed physical activity?*

If yes, please state bone/joint.

6. Has a doctor ever recommended medication for your blood pressure or heart condition?*

7. Do you suffer from Diabetes Mellitus?*

8. Do you suffer breathlessness after slight exertion?*

9. Is there any possibility that you may be or are pregnant?*

10. Are you over 65 and unaccustomed to regular exercise?*

11. Are you aware through your own experience, or a doctors advise, of any reason against you exercising without medical supervision?*

Part 2

Do you currently:

1. Have known elevated blood pressure (over 160/100)?*

2. Have known elevated cholesterol levels (over 6.2)?*

3. Smoke tobacco?*

4. Have a family history of coronary or any other circulatory disease?*

Disclaimer

If you have ticked YES to any questions in part 1 and/or two of the YES boxes in part 2 we recommend that you visit your doctor before starting any exercise. Whilst these questions are designed to advise you about the safety of exercise, you are reminded that Cranleigh School Sports Centre cannot be held responsible for your health. It is your responsibility to consult with your doctor if you are in any doubt about the safety for you to exercise.

It is my responsibility to consult with my doctor if I am in doubt about the safety for me to exercise.*

I agree.

I have viewed the online induction video which shows how to use the equipment safely and will ask staff for assistance if I am at all unsure.

I agree.

I have read and understand all the above information.*

I agree.

Monday	9:00 am – 9:30 pm
Tuesday	9:15 am – 10:00 pm
Wednesday	9:15 am – 10:00 pm
Thursday	8:30 am – 10:00 pm
Friday	9:15 am – 9:30 pm
Saturday	8:30 am – 5:00 pm
Sunday	9:00 am – 6:00 pm

Pre-Induction Questionnaire

Part 1

Part 2

Disclaimer