* Denotes required fields
Title *
First Name *
Surname *
Occupation *
Date of Birth *
Address *
Your email *
Mobile Number *
Emergency Contact Name *
Emergency Contact Number *
If answering 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.
Has your doctor ever said that you have a heart condition and that you should only do exercise recommended by your doctor? YesNo
In the past month, have you had chest pain when you are not doing physical activity? YesNo
Do you have a bone or joint problem that could be made worse by a change in your physical activity? YesNo
Are you diabetic? YesNo
Are you taking any medication? YesNo
Do you feel pain in your chest when you do physical activity? YesNo
Do you lose your balance because of dizziness or do you ever lose consciousness? YesNo
Is your doctor currently prescribing drugs for your blood pressure or heart condition? YesNo
Do you have a chronic cough or a condition that affects your breathing (hayfever, asthma?) YesNo
Do you know of any other reason why you should not do physical activity? YesNo
Please provide any further information related to the prior 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. *
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.
