Par Q Form Canada Water – Drop-In First Name *Email Address *Phone Number *DOB *How did you hear about us?FacebookInstagramGoogle AdLeafletOtherHas your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *In the past month, have you had a chest pain when you were not doing physical activity? *Do you feel pain in your chest when you do physical activity? *Do you lose balance because of dizziness or do you ever lose consciousness? *Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity? *Is your doctor currently prescribing medication for your blood pressure or heart condition? *Do you know of any other reason why you should not take part in physical activity? *Emergency contact details: Name and Phone Number *If you answered YES to one or more questions: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health. If you answered NO to one or more questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levelsI have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injuryHaving answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise.Email ConfirmationSubmit
