PROactive

Group: Ballers Academy

When using this form, you should:

Understand why you are submitting this information.
What your coach(s) are going to do with this information.
Your coach(s) policy for destroying this information (within a period of time or once you as a client has left).

PAR-Q - Short Version

Group: Ballers Academy

Client details:

DOB:

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PAR-Q - Short Version

Introduction

If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Please read each question carefully and answer honestly by indicating YES or NO.

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? YES NO

Do you feel pain in your chest when you do physical activity? YES NO

In the past month, have you had a chest pain when you were not doing physical activity? YES NO

Do you lose balance because of dizziness or do you ever lose consciousness? YES NO

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? YES NO

Is your doctor currently prescribing medication for your blood pressure or heart condition? YES NO

Do you know of any other reason why you should not take part in physical activity? YES NO

Confirm details

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 any of the 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 levels.

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PAR-Q - Short Version

Consent

This consent should be given by the participant or an adult/guardian. If under the age of 13 consent must by given by whoever holds parental responsibility for the child.

I understand that the submission of this information is voluntary and I consent for all of the information provided to be shared with and viewed by my organisation (including it’s staff), and being stored by Proactive Reporting for the purpose of providing the recognised service(s) provided by my organisation (Most regularly fitness, leisure, personal training, or class based exercise), and I understand how my data will be used. Full details here YES NO

Special Category Data – Health (Health related information, diet and nutrition, lifestyle, exercise relevant medical history, symptom related questions, structural health)

I understand that the submission of this information is voluntary, and I consent for all of the information to be shared with and viewed by my organisation (including it’s staff), in order for my organisation to advise me on whether the participant named should or should not commence/take part in physical activity and to help prescribe suitable and relevant activity levels and type. Full details here YES NO

I 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 injury. YES NO

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PAR-Q - Full Version

Group: Ballers Academy

Your personal details:

DOB:

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PAR-Q - Full Version

Emergency Contact Details:

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PAR-Q - Full Version

Your health goals:

What health goals would you like to achieve in the next 3 months?

Name 3 things you could do in order to improve your health?

What are your main reasons for starting a fitness programme?

General conditioning YES NO

Weight /fat loss YES NO

Stress management YES NO

Muscular strength YES NO

Aerobic fitness YES NO

Flexibility YES NO

No time YES NO

Appearance YES NO

Improve self-esteem YES NO

Other YES NO

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PAR-Q - Full Version

How would you describe your general health and fitness?

Have you ever done any structured exercise? YES NO

If ‘Yes’ what did you do?

What type of exercise do you enjoy the most?

What type of exercise do you dislike the most?

What would you say are the main barriers preventing you from exercising?

Lack of facilities YES NO

Injury/illness YES NO

Lack of knowledge YES NO

No motivation YES NO

Unfit YES NO

Family YES NO

No time YES NO

Appearance YES NO

Work YES NO

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PAR-Q - Full Version

Diet and Nutrition

Would you like any help or advice in changing the quality of your eating habits? YES NO

Do you follow any particular diet or eating patterns?

Lifestyle

Do you drink alcohol? YES NO

Do you smoke? YES NO

If you answered ‘Yes’, would you like help or advice to change these habits? YES NO

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PAR-Q - Full Version

Medical History

Have you had a major illness or injury in the last 5 years? YES NO

If ‘Yes’ please give details

Are you receiving treatment for any diagnosed medical condition? YES NO

If ‘Yes’ please give details

Are you taking any prescription medication? YES NO

If ‘Yes’ please give details

Please indicate if you ever experience any of the following symptoms. Do you:

Ever get unusually short of breath with very light exertion? YES NO

Ever have pain, pressure, heaviness, or tightness in the chest area? YES NO

Regularly have unexplained pain in the abdomen, shoulders or arm? YES NO

Ever have sever dizzy spells or episodes of fainting? YES NO

Regularly get lower leg pain during walking that is relieved by rest? YES NO

Ever experience palpitations or irregular heartbeats? YES NO

Are you currently pregnant or have you given birth in the last 6 months? YES NO

Having completed this questionnaire (or on the advice of my coach) I have sought medical advice and my GP has agreed that I may exercise. YES NO

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PAR-Q - Full Version

Structural Health

Please indicate on the figures below any aches, pains or problem areas

Front of body

Back of body

Please give details of any areas indicated

Are any of these injuries aggravated by exercise? YES NO

Are you currently receiving treatment for any structural problem? YES NO

Please indicate any other health problems you suffer from which you have not already mentioned.

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PAR-Q - Full Version

Consent

This consent should be given by the participant or an adult/guardian. If under the age of 13 consent must by given by whoever holds parental responsibility for the child.

I understand that the submission of this information is voluntary and I consent for all of the information provided to be shared with and viewed by my organisation (including it’s staff), and being stored by Proactive Reporting for the purpose of providing the recognised service(s) provided by my organisation (Most regularly fitness, leisure, personal training, or class based exercise), and I understand how my data will be used. Full details here YES NO

Special Category Data – Health (Health related information, diet and nutrition, lifestyle, exercise relevant medical history, symptom related questions, structural health)

I understand that the submission of this information is voluntary, and I consent for all of the information to be shared with and viewed by my organisation (including it’s staff), in order for my organisation to advise me on whether the participant named should or should not commence/take part in physical activity and to help prescribe suitable and relevant activity levels and type. Full details here YES NO

I 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 level of risk. YES NO

EDIT (LAST CHANCE) SUBMIT PAR-Q