Title *

First Name *

Surname *

Date of Birth *

Address *

Your email *

Mobile Number *

Emergency Contact Name *

Emergency Contact Number *

How many years have you suffered from back pain? (if applicable) *

Are there any long-standing issues with your back? E.g. sciatica, disc herniation *

Details of any current exercise: *

Has your doctor ever said that you have a heart condition AND that you should only do exercise recommended by your doctor? *
YesNo

Do you feel pain in your chest when you do physical activity? *
YesNo

In the past month, have you had chest pain when you are not doing physical activity? *
YesNo

Do you lose your balance because of dizziness or do you ever lose consciousness? *
YesNo

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
YesNo

Is your doctor currently prescribing drugs for your blood pressure or heart condition? *
YesNo

Are you diabetic? *
YesNo

Are you having trouble with your bowel, wind or urinary urges? *
YesNo

Have you been diagnosed with a specific back condition? *
YesNo

Have you had spinal surgery? *
YesNo

Have you received physio/osteopathy/chiropractor treatments in the past? *
YesNo

Are you currently receiving any of the above treatments? *
YesNo

Have you had any other type of surgery other than spinal related? *
YesNo

Does your back pain affect your sleep? *
YesNo

Does your back pain affect your self-confidence/self-esteem? *
YesNo

Are you or have you ever been an elite athlete? Runner, gymnast, trampolining or any sport that involved regular contact? *
YesNo

Do you have a history or low back pain or any other type of back pain? *
YesNo

Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx?) *
YesNo

Do certain foods trigger your back pain? *
YesNo

Do you have a chronic cough or a condition that affected your breathing (smoking, hayfever, asthma?) *
YesNo

Are you or have you been overweight? *
YesNo

Do you frequently lift heavy weights (Gym, work, children, caring for disabled or elders?) *
YesNo

Do you know of any other reason why you should not do physical activity? *
YesNo

Please provide any further information related to the above issues here, if applicable

This physical activity clearance is valid for 12 months from the date that it is completed and becomes invalid if your condition changes so that you would answer YES to any of the medical questions.

I have also read and understood, the separately provided Digital and Physical Exercise Waiver. *

I have read, understood, and accurately completed this questionnaire. I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury. *

What are your goals for participating in exercise? What part of your physical or mental wellbeing are you most motivated on improving right now? *

What liquids do you drink during the day and how much of each type? *

How would you describe your current diet? Include any regular cravings you have. *

How are your stress levels? (1-low, 5-high). What triggers your stress? *

I understand that Sarah Gatford of SgFit Studio will hold my personal information (including responses on PARQ) securely (password protected) and will not share this with any third parties. If at any time I do not wish my details to be held and no longer wish to use Sarah Gatford Lifestyle and Fitness, I can request for my personal information to be destroyed correctly. *

I wish to subscribe to the SgFit Studio mailing list where information will be sent for newsletters and relevant purposes. My email will not be shared with any third parties and I can unsubscribe from this mailing list at any time. *