PAR-Q | Tom Timney Personal Training

Personal Details

Full name *

Date of birth *

Email address *

Phone number *

Emergency contact name *

Emergency contact phone *

Health Questions

Please answer YES or NO for each question. If you answer YES, a box will appear for you to provide details.

1. Has a doctor ever told you that you have a heart condition, or that you should only do physical activity recommended by a doctor?

Please provide details and confirm you have received medical clearance to exercise

2. Do you ever feel pain in your chest when you do physical activity?

Please describe when this occurs and whether you have spoken to a doctor

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

Please provide details

4. Do you ever lose your balance because of dizziness, or do you ever lose consciousness?

Please describe how often this occurs and any known cause

5. Do you have a bone or joint problem that could be made worse by physical activity?

Please describe the condition, area affected and any limitations

6. Is a doctor currently prescribing medication for your blood pressure or a heart condition?

Please list the medication and confirm your doctor is aware you are starting an exercise programme

7. Do you have diabetes (Type 1 or Type 2)?

Please confirm whether your condition is managed and any exercise-related considerations

8. Do you have asthma or any other respiratory condition?

Please describe the condition and whether you use any medication such as an inhaler

9. Are you currently pregnant or have you given birth in the last 12 weeks?

Please confirm how far along you are or how recently you gave birth, and whether you have medical clearance to exercise

10. Do you have any current injuries, pain or physical limitations that would affect your ability to exercise?

Please describe the injury or limitation, how long you have had it and any advice received

11. Are you aware of any other reason why you should not do physical activity?

Please provide as much detail as possible

Additional Information

Anything else Tom should know before your first session?

Declaration

I confirm that the information provided on this form is honest and accurate to the best of my knowledge. I understand that it is my responsibility to inform the Trainer of any changes to my health or physical condition before future sessions. I acknowledge that the Trainer is not a medical professional and that any concerns about my health should be directed to a qualified doctor.

I confirm the above declaration and agree that this information is accurate to the best of my knowledge *

Full name (as signature) *

Date *

Your responses will be sent securely and stored confidentially.

Something went wrong. Please try again or contact Tom directly on 07984 590 875.

Physical Activity
Readiness Questionnaire

PAR-Q Submitted

Physical ActivityReadiness Questionnaire

PAR-Q Submitted

Physical Activity
Readiness Questionnaire