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PT PARQ

Hi!

This Physical Activity Readiness Questionnaire (PAR-Q) is designed to help me understand the health, mobility, and safety needs of the person who will be taking part in personal training sessions. Because my client group includes older adults and individuals with reduced mobility, this form is especially important for ensuring that exercise is delivered safely, appropriately, and with full awareness of any medical conditions or limitations.

Please provide as much detail as possible in your answers; the more information I have, the better I can tailor movements, reduce risk, and create a safe and supportive training environment.

I fully understand that in many cases this form may be completed on behalf of the client (for example, by a spouse, adult child, or carer). If you are filling this in for someone else, please indicate this clearly in the space provided and answer based on the client’s current health, abilities, and daily challenges.

Thank you for taking the time to complete this thoroughly; it helps me deliver the safest and most effective support possible.

Thank you,

Vicky

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Question 1 of 23

Clients Name, Address, Telephone Number, Email address & DOB

Question 2 of 23

If completing form on behalf of client; your Name, Address, Email, DOB & relationship to client.

Question 3 of 23

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

If Yes Please give details:

Question 4 of 23

2. Do you ever feel chest pain during physical activity?

 

If yes, please give details:

Question 5 of 23

3. Do you experience chest pain at rest or at any time not related to exercise?

 

If yes, please give details:

Question 6 of 23

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

 

If yes, please give details:

Question 7 of 23

5. Have you ever been diagnosed with high or low blood pressure?

 

If yes, please provide details and medication (if any):

Question 8 of 23

6. Do you have any bone, joint, or muscle problems that could be worsened by exercise?

 

(Examples: arthritis, osteoporosis, back pain, joint replacements, previous fractures)

If yes please give details:

Question 9 of 23

7. Have you had any falls in the past 5 years?

 

If yes, how many? Did the falls cause injury? Treatment/rehabilitation received. Please indicate if this treatment is still on going

Question 10 of 23

8. Do you use any mobility aids such as a walker, cane, or frame or wear a personal safety alarm?

 

If yes please give details:

Question 11 of 23

9. Do you have difficulty with any of the following:

 

  • Walking for more than a few minutes

  • Getting up from a chair

  • Climbing stairs

  • Standing for long periods

  • Getting up from the floor

    If yes, please explain:

Question 12 of 23

10. Are you currently taking any prescribed medications?

 

If yes please list along with dosage, frequency and any side effects experienced:

Question 13 of 23

11. Have you been diagnosed with any of the following:

  • Diabetes

  • Stroke / TIA

  • Parkinson’s

  • Dementia or memory issues

  • COPD or breathing difficulties

  • Osteoporosis / osteopenia

  • Heart disease

  • Peripheral neuropathy

If yes please give further details:

Question 14 of 23

12. Do you have any issues with balance or fear of falling?

 

If yes please give details

Question 15 of 23

13. Do you experience swelling in your legs, ankles, or feet?

 

If yes please give details

Question 16 of 23

14. Do you ever feel unusually short of breath at rest or with light activity?

 

If yes please give details

Question 17 of 23

15. Do you have any concerns about exercising that you’d like me to be aware of?

 

If yes please give details

Question 18 of 23

16. Are there any daily activities you struggle with or find tiring?

(Examples: carrying shopping, dressing, bathing, cooking)


If yes please give details

Question 19 of 23

17. What are your goals for working together?

 

(e.g., strength, mobility, confidence, fall prevention, independence)
Answer:

Question 20 of 23

18. Please provide Emergency Contact Information for someone in the area:

 

Name:
Phone:
Relationship:

Question 21 of 23

19. Please provide GP / Medical Contact:

 

GP Surgery:
GP Name (if known):
Phone:

Question 22 of 23

Please indicate if there is anything else you would like to tell me or think I should know in relation to our sessions together

Question 23 of 23

20. Client Declaration:

By typing my name below and returning this form by email, I confirm that the information provided is true and accurate to the best of my knowledge. I understand that this emailed response serves as my digital signature in place of a handwritten one.

If I am completing this form on behalf of the client, I confirm that I have done so with their knowledge and consent, and that the information given accurately reflects their current health and circumstances.

I understand that it is my responsibility to inform the trainer of any changes to the client’s health or medication.

 

Typed Name:
Relationship to Client (if completing on their behalf):
Date:

Confirm and Submit