Form – APG Training

Physical Activity Readiness Questionaire

Personal Details

First Name

Last Name

Email Address

Phone Number

Date of Birth

Gender

Male Female

Emergency Contact Details

First Name

Last Name

Phone Number

Relationship to you

1. Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise?

Yes No

2. Do you have high blood pressure?

Yes No

3. Do you have low blood pressure?

Yes No

4. Do you have Diabetes Mellitus or any other metabolic disease?

Yes No

5. Has your doctor ever said you have raised cholesterol (serum level above 6.2mmol/L)

Yes No

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

Yes No

7. Have you ever felt pain in your chest when you do physical exercise?

Yes No

8. Is your doctor currently prescribing you any drugs or medication?

Yes No

9. Have you ever suffered from unusual shortness of breath at rest or with mild exertion?

Yes No

10. Is there any history of Coronary Heart Disease in your family?

Yes No

11. Do you often feel faint, have spells of severe dizziness or have lost consciousness?

Yes No

12. Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)?

Yes No

13. Do you currently smoke?

Yes No

14. Do you NOT currently exercise on a regular basis (at least 3 times a week) and/or work in a job that is physically demanding?

Yes No

15. Are you, or is there any possibility that you might be pregnant?

Yes No

16. Do you know of any other reason why you should not participate in a program of physical activity?

Yes No

If you answered YES to one or more questions:

If you have not recently done so, consult with your doctor by telephone or in person before increasing your physical activity and/or taking a fitness appraisal. Tell your doctor what questions you have answered 'yes’ to on your PAR-Q or present your PAR-Q copy. After medical evaluation, seek advice from your doctor as to your suitability for:

Unrestricted physical activity starting off easily and progressing gradually
Restricted or supervised activity to meet your specific needs, at least on an initial basis

No to all questions: If you answered your PAR-Q accurately, you have reasonable assurance of your present suitability for:

A graduated exercise programme
A fitness appraisal

Finding the right programme for you

What is your occupation?

What hours do you work?

Please specify any personal circumstances which you feel may affect your fitness programme?

What (if any) type of exercise do you currently do, including recreational activities (eg. Football, Tennis, Golf etc) and how often?

Depending on your exercise history, what types of exercise/equipment do you enjoy?

What types of exercise (if any) do you dislike? Give a brief description of why you dislike them?

To help develop the right programme for you please rank the following goals in order of importance: (1=Not Very - 5=Very)

If you answered 3 or higher to "Rehabilitation" please specify which area you are looking to focus on (eg. shoulder, arm, back, knee, hip, etc)?

Acceptance

I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities that may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.

Contact me

Mobile : 07756 195788

Email : ant@apgtraining.co.uk

A.P.G. Training

Milton Pools Farm

Great Milton

Oxfordshire

OX44 7JE

Opening Hours

Monday: 07:00 – 21:00

Tuesday: 07:00 – 21:00

Wednesday: 07:00 – 21:00

Thursday: 07:00 – 21:00

Friday: 07:00 – 21:00

Saturday: 07:00 – 18:00

Sunday: Closed