Group: Ballers Academy

SHORT VERSION

FULL VERSION

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

Ballers Academy

Client details:

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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?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had a chest pain when you were not doing 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?

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.


Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise.

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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

Please confirm you understand how your data will be used.


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

Please confirm you understand how your data will be shared / viewed.


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.

 

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PAR-Q - Full Version

Ballers Academy

Your personal details:

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PAR-Q - Full Version

Emergency Contact Details:

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PAR-Q - Full Version

Your health goals:

What are your main reasons for starting a fitness programme?

General conditioning
Weight /fat loss
Stress management
Muscular strength
Aerobic fitness
Flexibility
No time
Appearance
Improve self-esteem
Other

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PAR-Q - Full Version

Have you ever done any structured exercise?

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

Lack of facilities
Injury/illness
Lack of knowledge
No motivation
Unfit
Family
No time
Appearance
Work

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PAR-Q - Full Version

Diet and Nutrition

On a scale of 1-10 (with 1 being poor and 10 being excellent) how would you assess the quality of your eating habits?
Would you like any help or advice in changing the quality of your eating habits?

Do you follow any particular diet or eating patterns?

Lifestyle

Do you drink alcohol?
Do you smoke?
If you answered ‘Yes’, would you like help or advice to change these habits?

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PAR-Q - Full Version

Medical History

Have you had a major illness or injury in the last 5 years?
Are you receiving treatment for any diagnosed medical condition?
Are you taking any prescription medication?

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

Ever get unusually short of breath with very light exertion?
Ever have pain, pressure, heaviness, or tightness in the chest area?
Regularly have unexplained pain in the abdomen, shoulders or arm?
Ever have sever dizzy spells or episodes of fainting?
Regularly get lower leg pain during walking that is relieved by rest?
Ever experience palpitations or irregular heartbeats?
Are you currently pregnant or have you given birth in the last 6 months?

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.

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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?
Are you currently receiving treatment for any structural problem?

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

Please confirm you understand how your data will be used.


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

Please confirm you understand how your data will be shared / viewed.


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.

EDIT (LAST CHANCE) SUBMIT PAR-Q