Dig Deep Fitness Pre-Activity Readiness Questionnaire (par-q) Note

Dig Deep Fitness Pre-Activity Readiness Questionnaire (PAR-Q)

Note: this information will be kept confidentially.

Once you have completed your PAR-Q please print it out and bring it along to your first INSANITY / Kangoo class, or email it to [e-mail]

Name: __________________________________________

D.O.B _________________________________________

Health related questions:

Please type YES or NO to the following: YES NO

Q1. Has your doctor ever said that you have a heart condition? ____ ____

Q2. Do you have pains in your chest when performing physical activity? ____ ____

Q3. Have you had chest pain when you were not doing physical activity? ____ ____

Q4. Do you lose your balance due to dizziness, or ever lose consciousness? ____ ____

Q5. Is there a history of coronary disease in your immediate family? ____ ____

Q6. Do you suffer from high or low blood pressure? ____ ____

Q7. Do you suffer from high cholesterol ____ ____

Q8. Are you pregnant now or have you given birth within the last 6 months? ____ ____

Q9. Have you had surgery recently? ____ ____

If you have marked YES to any of the above, please give more details:

_____________________________________________________________________________

_______________________________________________________________

Q10. Do you have any chronic illness or physical limitations such as Asthma, diabetes? YES/NO

Please specify ________________________________________________________________

Q11. Do you have any injuries, bone/joint or orthopedic problems such as bursitis, bad knees, back, shoulder, wrist or neck issues? YES/ NO Please specify _____________________________________

Q12. Do you take any medications, either prescription or non-prescription regularly? YES/ NO

What is the medication for?_______________________________________________________

How does this medication affect your ability to exercise or achieve your fitness goals?

Q13. Do you know of any other factor which may affect your ability to participate in physical activity?

Please specify _____________________________________ YES/ NO

If you answered:

Yes to one or more questions

Talk with your doctor by phone or in person before you start becoming much more physically active and before you begin INSANITY classes as participation can be refused. Tell your doctor about the PAR-Q, your intended training and which question(s) you answered YES.

No to all questions

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can start becoming more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.

Delay becoming much more active:

If you are not feeling well because of a temporary illness such as a cold or fever – wait until you feel better.

If you are pregnant – talk to your doctor before you start becoming more active.

If your health changes so that you then answer YES to any of the above questions, consult your doctor. Similarly, if at any stage your details change, then it is your responsibility to complete a new

Kangoo Boots

Dig Deep Fitness do not take any responsibility for damage caused to personal boots. We advise you to wear only Kangoo official boots and cannot be held responsible for any injury caused during Kangoo Jump Classes or Insanity Live classes.

Emergency Contact:

Please provide the name and number of someone who we can call in the event of an emergency:

Name: Number:

I confirm I have read and understood this PAR-Q and have completed it to the best of my knowledge.

I confirm that if I answered YES to any questions I will seek advice from my doctor BEFORE taking part in an INSANITY workout class.

I confirm that if my health changes so that I then answer YES to any of the above questions it is my responsibility to inform Dig Deep Fitness and complete a new Par-Q

Name: Date:

Signature: Date:

Address:

Copyright Dig Deep Fitness