Bootcamp PAR-Q – Bee MumFit

Name

First

Last

DOB (DD/MM/YY)

Date (DD/MM/YY)

Email

Number

Doctors Details

Address

Would like to be added to the What’s App Group?

Yes

No

I consent to photos being taken during class and used on social media?

Yes

No

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

Yes

No

Do you feel pain in your chest when performing physical activity?

Yes

No

Have you experienced chest pain when NOT performing physical activity in the last month?

Yes

No

Do you lose your balance because of dizziness or have you lost consciousness recently?

Yes

No

Do you have any bone or joint problems such as arthritis, which could be aggravated through physical activity?

Yes

No

Is your doctor currently prescribing you medications for high blood pressure or a heart condition?

Yes

No

Have you had an operation in the last 12 months?

Yes

No

Is there any reason why you should NOT participate in physical activity?

Yes

No

IF you answered YES to the final question or would like to add more details please state below:

If you answered no to all the PAR-Q questions, you can be reasonably sure that you can exercise safely and have low risk of having any medical

complications from exercise. It is still important to start slowing and increase gradually. It may also be helpful to have a fitness assessment with a fitness instructor or personal trainer in order to determine where to begin.

PLEASE NOTE: If your health changes so that subsequently you answer YES to any of the above questions, inform your fitness or health professional immediately. Ask whether you should change your physical activity or exercise plan.

Declaration: 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.

Name

First

Last

Date (DD/MM/YY)

If you answered yes to one or more questions, are older than age 40 and have been inactive or are concerned about your health, consult a physician before taking a fitness test or substantially increasing your physical activity. You should ask for a medical clearance along with information about specific exercise limitations you may have.

In most cases, you will still be able to do any type of activity you want as long as you adhere to some guidelines.

When to delay the start of an exercise program:

If you are not feeling well because of a temporary illness, such as a cold or a fever, wait until you feel better to begin exercising. If you are or may be pregnant, talk with your doctor before you start becoming more active.

Declaration: Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise.

Name

First

Last

Date (DD/MM/YY)

PLEASE 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 7 questions.

BY COMPLETING AND SUBMITTING THIS FORM YOU ARE CONFIRMING THAT YOU HAVE READ AND AGREE TO THE TERMS ABOVE.