ECU Sport and Fitness
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)
Name: ______________________________________________________ Tick if under 18
Name: ___________________________________ Phone: ___________________________
Age: _______
Date of Birth: ______/______/______
Sex:
M
F
Emergency Contact: ___________________________ Phone: ________________________
Do you suffer from any of the following conditions? Further information (e.g. past injuries, medications,
recent surgery) will assist your gym instructor in prescribing a suitable program for you.
Medical Condition
YES / NO
Medical Condition
YES / NO
Medical Condition
YES / NO
Epilepsy?
Y/N
High cholesterol?
Y/N
Hernia?^
Y/N
Thyroid condition?
Y/N
Diabetes?*
Y/N
Stroke / heart condition?**
Y/N
Recent back or neck
problems?
Y/N
History of asthma or
breathing difficulties?^
Y/N
Any exercise induced
condition?^
Y/N
Other joint or muscular
problems?
Y/N
Any chronic illness or
disease?^
Y/N
Chest pains?**
Y/N
Arthritis / Osteoporosis?
Y/N
High blood pressure?*
Y/N
Pregnant?^
Y/N
Dizzy spells?
Y/N
Rheumatic Fever?*
Y/N
Circulation problems?^
Y/N
Further information/past and current injuries:
* Dr. Recommendation ** Dr. Referral ^ Dr. Rec/Ref
_______________________________________________________________________
Rec/Ref
_______________________________________________________________________
___________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Are you on any medication? _________________________________________________
_______________________________________________________________________
Have you had surgery in the past 12 months? _____________________________________
_______________________________________________________________________
I agree that I have disclosed all relevant information in writing as per the above. I agree that I have
made ECU Sports aware of all physical, mental or health conditions, which could be aggravated,
worsened or be impaired by physical exercise or participation in programs.
In the event that an incident occurs whilst I am attending or using the facilities at ECU Sports I agree
to immediately report the details of the incident to an ECU Sports staff person.
Signature (member): ________________________________Date: ______/______/______
Instructor signature: ________________________________Date: ______/______/______
ature (
Fitness Appraisal
All printed copies are uncontrolled
As at February 2015
Issue 8
ECU Sport and Fitness
FITNESS APPRAISAL – (Instructor use only)
Membership
length
Visits per
week
Duration of
visit
Goals
Current
exercise
Training
history
General
Instructor Age
HR
(rest)
(bpm)
Blood
Weight Height Flexibility
Pressure
(kg)
(cm)
(cm)
Step Test
(HR)
Max │ 1 min
Test
Date
1.
__/__/__
∕
│
2.
__/__/__
∕
│
3.
__/__/__
∕
│
4.
__/__/__
∕
│
5.
__/__/__
∕
│
Girth Measurements
Test
Arm (L/R)
(cm)
1.
│
2.
Chest
(cm)
Waist
(small &
navel)
Hips
(glute
widest part)
Thigh (L/R)
(cm)
Calf (L/R)
(cm)
│
│
│
│
│
│
│
3.
│
│
│
│
4.
│
│
│
│
5.
│
│
│
│
Healthy Heart Check Score & Disease Risk Indicators:
Test
Score
Dr Referral or
Recommendation?
Test
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
Fitness Appraisal
All printed copies are uncontrolled
BMI
Wt (kg)/Ht (m²)
Waist: Hip Ratio
As at February 2015
Issue 8
ECU Sport and Fitness
General
Instructor Age
HR
(rest)
(bpm)
Blood
Weight Height Flexibility
Pressure
(kg)
(cm)
(cm)
Step Test
(HR)
Max │ 1 min
Test
Date
6.
__/__/__
∕
│
7.
__/__/__
∕
│
8.
__/__/__
∕
│
9.
__/__/__
∕
│
10.
__/__/__
∕
│
11.
__/__/__
∕
│
12.
__/__/__
∕
│
Girth Measurements
Test
Arm (L/R)
(cm)
6.
│
7.
Chest
(cm)
Waist
(small &
navel)
Hips
(10cm from
pelvic crest)
Thigh (L/R)
(cm)
Calf (L/R)
(cm)
│
│
│
│
│
│
│
8.
│
│
│
│
9.
│
│
│
│
10.
│
│
│
│
11.
│
│
│
│
12.
│
│
│
│
Healthy Heart Check Score & Disease Risk Indicators:
Test
Score
Dr Referral or
Recommendation?
Test
6.
6.
7.
7.
8.
8.
9.
9.
10.
10.
11.
11.
12.
12.
Fitness Appraisal
All printed copies are uncontrolled
BMI
Wt (kg)/Ht (m²)
Waist: Hip Ratio
As at February 2015
Issue 8
ECU Sport and Fitness
Date
Notes
Fitness Appraisal
All printed copies are uncontrolled
As at February 2015
Issue 8