Physical Activity Readiness Questionnaire (PAR Q) Step 1 of 3 33% Name* First Last Date Of Birth* DD slash MM slash YYYY Address* Address Line 1 Address Line 2 Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone* Essential Physical Activity Readiness Questions (PARQ)Please answer honestly by indicating YES or NO.Heart Condition*Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? Yes No Activity Chest Pain*Do you feel pain in your chest when you do physical activity? Yes No Resting Chest Pain*In the past month, have you had a chest pain when you were not doing physical activity? Yes No Dizziness*Do you lose balance because of dizziness or do you ever lose consciousness? Yes No Bones & Joints*Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity? Yes No Medication*Has your Doctor ever said that you suffer from high blood pressure? Yes No Other Reasons*Do you know of any other reason why you should not take part in physical activity? Yes No If you have answered YES please provide further details.I confirm that I have understood and answered all questions in this section accurately to the best of my knowledge. I understand that by answering YES to any of the above questions I should consult my GP before taking part in Jo Stephens Fitness' classes.Signature*Date* MM slash DD slash YYYY Further QuestionsThe questions in this section relate to mobility and other health conditions that may require a consultation with Jo Stephens before commencing in order to tailor certain exercises to your needs. Please answer honestly by indicating YES or NO.Diabetic*Are you diabetic? Yes No Asthma*Do you suffer from Asthma? Yes No Epilepsy*Do you suffer from Epilepsy? Yes No Pregnant*Are you Pregnant or have been within the last 6 months? Yes No Mobility/Injury*Have you any current or previous injuries that effect your mobility or ability to perform certain exercises? Yes No Wrists*Do you struggle to put weight on your wrists or experience any wrist pain in general? Yes No Floor*Do you struggle to get down to the floor and backup again? Yes No If you have answered YES to any of the questions in this section please provide details.Please use this section to note down any specific GOALS, CONCERNS or GENERAL INFORMATIONI 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 understand that I am responsible for monitoring myself throughout exercising with Jo Stephens Fitness. I take full responsibility of my own actions. I will inform my trainer if my physical fitness changes.Signature*Date* MM slash DD slash YYYY
