Physical Activity Readiness Questionnaire

Online submission is temporarily our of action – please download the following PDF form and email to – thank you for your co-operation.

Your Full Name (required) :

Date of Birth :

Your valid Email address (required) :

Your Address

Todays Date (required) :

The questions below will indicate if you need to check with your doctor before you start exercising. If you are over 69 years of age and not currently active you should consult with your doctor prior to commencing an exercise regime.

Please read the questions below and answer honestly

Has your doctor ever said that you have a heart condition and you should only do physical activity recommended by a doctor?  YES NO

Do you have high blood pressure?  YES NO

Do you have any pain in your chest when you do physical activity?  YES NO

In the past have you ever had chest pain during 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 that could be made worse by a change in your physical activity?  YES NO

Are you currently taking any prescribed medication excluding the contraceptive pill?  YES NO

Do you know of any reason why you should not be undertaking physical activity?  YES NO

If you have answered any of the above questions with a yes you will need to consult with your GP BEFORE you start becoming more physically active or BEFORE you have a fitness appraisal. We will need written confirmation from your GP before you begin using the gym.


Are you currently undergoing any of the following?

 Diet modification Homeopathy Herbs Fasting Chiropractic Conventional drugs Vitamins/Minerals Acupuncture


Current health problems for which you are being treated:

Current medications (prescription or over-the-counter)
Major hospitalisations, surgeries or injuries: Please list all procedures, any complications and dates:
Year Operation, illness or injury Outcome
Year Operation, illness or injury Outcome
Year Operation, illness or injury Outcome


Do you consider yourself to be:  Underweight Just right Overweight


Any unintentional weight change of 10lbs or more in the last three months?  YES NO


Are you recovering from a cold or flu?  YES NO


Are you pregnant?  YES NO


Select the level of stress you are currently experiencing (1 being the lowest) 1 10

Identify the major causes of this stress (eg, work, personal life, finance, etc)


How many hours do you sleep each night?


Is your sleep disturbed at the same time each night? YES NO

If yes, what time?


Time of day you feel MOST energy/least symptoms?

Time of day you feel LEAST energy/most symptoms?


Medical History

 Arthritis Allergies/hayfever Asthma Alcoholism Alzheimer’s disease Autoimmune disease Blood pressure concerns Bronchitis Cancer Chronic fatigue syndrome Carpal tunnel syndrome Cholesterol (elevated) Circulatory problems Colitis  Dental problems Depression Diabetes Drug addiction Eating disorder Epilepsy Emphysema Eyes, ears, nose, throat problems Environmental sensitivities Fibromyalgia Food intolerance Gastroesophagal reflux disease  Genetic disorder Glaucoma Gout Heart disease Infection (chronic) Inflammatory bowel disease Irritable bowel syndrome Kidney or bladder disease Liver or gallbladder disease (stones) Mental illness Migraine headaches Neurological (Parkinsons, paralysis)  Sinus problems Stroke Thyroid trouble Obesity Osteoporosis Pneumonia Sexually transmitted disease Seasonal affective disorder Skin problems Tuberculosis Ulcer Urinary tract infection Varicose veins

Health habits

 Tabacco Cigarettes per day
 Alchohol Units per week

Declaration

I have read, understood and completed the above questionnaire and acknowledge that there are risks and dangers inherent in physical exercise and duly undertake the activity at my own risk. Any liability on the part of the operators is excluded unless negligence can be proven. I agree to observe the rules and conditions of membership. I also acknowledge that I must not use any piece of equipment for which I have not been shown how to use by an instructor. I confirm that the information which I have provided is correct at this time and should I become aware of any relevant changes to my health or condition, I will inform an instructor.

By submitting this questionnaire you are acknowledging the above to be true.


if you are experiencing any difficulties with the online form submission please download and complete the PDF form below. Thank you.

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Physical Activity Readiness Questionnaire September 10, 2014