Health Questionnaire

PAR-Q - Stotfold Runners

You will need to fill out one of these forms before commencing any physical activity programme with Pete Luxford Personal Training or Stotfold Runners. Your trainer will then bring the printed version for you to sign before your first session.

• PERSONAL DETAILS

• Your Name*
  FirstLast
• Date of Birth*
  DD

  MM

  YYYY
• Your Address*
  Street AddressAddress Line 2CityZip / Postal Code
• Your Phone Number*
• Your Email Address

• EMERGENCY CONTACT DETAILS

• Name of Emergency Contact*
  FirstLast
• Emergency Contact Phone Number*
• Relationship to You (optional)

• MEDICAL HISTORY

• 1. Have you ever suffered from heart trouble?*
  • YES
  • NO
• 1a. Please supply further details here*
• 2. Do you suffer from chest pains?*
  • YES
  • NO
• 2a. Please supply further details here*
• 3. Do you ever have spells of dizziness or feel faint?*
  • YES
  • NO
• 3a. Please supply further details here*
• 4. Do you, or have you ever had, high or low cholesterol levels?*
  • HIGH
  • LOW
  • NEITHER
  • DON'T KNOW
• 4a. Please supply further details here*
• 5. Do you, or have you ever suffered from Asthma, or any other chest ailments?*
  • ASTHMA
  • OTHER
  • NONE
• 5a. Please supply further details here*
• 6. Do you suffer from any back pain or other orthopaedic problems?*
  • YES
  • NO
• 6a. Please supply further details here*
• 7. Do you suffer from migraines or severe headaches?*
  • YES
  • NO
• 7a. Please supply further details here*
• 8. Are you recuperating from a recent illness or injury?*
  • YES
  • NO
• 8a. Please supply further details here*
• 9. Is there any other condition, medical or otherwise that may affect your ability to perform exercise? This includes, but is not limited to, recent childbirth, allergies, epilepsy, restricted levels of movement, recreational drug use, etc.*
  • YES
  • NO
• 9a. Please supply further details here*
• 10. Are you currently taking any form of medication, prescription or otherwise?*
  • YES
  • NO
• 10a. Please supply further details here, including any known side effects that may affect your ability to exercise.*
• 11. Are you pregnant?*
  • YES
  • NO
• 11a. Please supply further details here, including due date, and any other information that may affect your ability to exercise*
• 12. Have you ever broken any bones or suffered from skeletal pains?*
  • YES
  • NO
• 12a. Please supply further details here*
• 13. Is there any history of heart disease in your immediate family (under the age of 55)?*
  • YES
  • NO
• 13a. Please supply further details here*
• 14. Do you smoke?*
  • YES
  • NO
• 14a. How many a day?*
  • 1-5
  • 6-10
  • 11-15
  • 16+

• DISCLAIMER and ACKNOWLEDGEMENT

  IF YOU HAVE ANSWERED YES TO ANY OF QUESTIONS 1-14 YOU ARE ADVISED TO SEEK MEDICAL ADVICE BEFORE COMMENCING ANY EXERCISE SESSION. Please read the following carefully before selecting "I agree".
• I have been informed both verbally and in writing that if I answer "YES" to any of the questions 1-14 listed on the PAR-Q form, I should seek medical advice/approval before commencing an exercise session*
  • I AGREE
• I agree that if I wish to continue on an exercise programme WITHOUT taking the medical advice suggested above, I do so entirely at my own risk*
  • I AGREE
• I confirm that I have read, fully understood, and answered the above questions honestly and to the best of my knowledge. I understand that the instructor cannot be held responsible for any injuries or ill health of any kind arising following the attendance of any exercise session*
  • I AGREE

• SIGNED________________________________________

  Click submit now and your trainer will print out the form for you to sign before your first session.

• INSTRUCTOR___________________________________

• DATE:_________________________________________

About the Author

I am a Personal Trainer working in the Letchworth, Baldock, Hitchin, Stotfold and Biggleswade area who has been running for 4 years. I strongly believe that everyone can run, but many of us don't know how to start. Running Clubs, like any other new experience can be daunting so I am dedicated to making everyone feel welcome, regardless of ability.

1 Comment

1. Reply

   ian lewer

   Posted April 21, 2011 at 9:50 PM

   hi to all my name is Ian, and live in stotfold,i have been running for a bout a year and a half roughly, about three times a week i am now at the stage where i would like to up my game and learn more about pacing speed work ect. Hopefully do the BIG ONE next year the Virgin London Marathon….look forward to my 1st trainning nite with the Stotfold Runners