Pre Activity Readiness Questionaire Form (PAR-Q-Form)

Please fill out the following form
in order to participate within our Gym and our activities.

Personal Details:

Address:

* required

Gender?

Male

Female

Other

Prefer not to say

Emergency Contact:

Medical Questions:

Answer the following questions as honestly as you can and provide as much relevant information you think is necessary. Answer the following questions by checking the box if the answer is YES to the question (if you should answer YES to any of the questions please provide further details in the space provided).

Do you currently or have you ever suffered from any of the following conditions?

1) Heart problems

2) Circulatory problems?

3) Blood pressure problems?

4) Joint, movement problems?

5) Feel dizzy or imbalance during exercise?

6) Currently pregnant or recently gave birth?

If you answered YES / checked any box above, please give more details:

Medical History:

Do you crrently receive meical care or do any of the following affect you?

1) Back or Spinal Pain

2) Headaches or Migraines

3) Have you recently had surgery?

4) Currently being prescribed medication?

5) Diabetes?

6) Asthma or Breathing Problems?

7) Is there any other reason that you believe may prevent you from taking part in regular activity?

If you answered YES / checked any box above, please give more details:

I have answered all questions in this form honestly and I am aware that if I have answered YES/Checked any of the boxes affirming the questions I will need to consult my GP before commencing an exercise program. If I am affected by any of the symptoms or questions mentioned above at a later date I agree to inform GymBlok of the hanges to my health and fitness.

Thanks for submitting!

Unit D, Northfield Point

Cunliffe Drive

Kettering,

NN16 9QJ

Mail: hello@gymblok.com
Tel: +44 (0) 7540 397 571

Opening Hours

Mon-Fri: 6AM to 9PM

Saturday: 8AM to 5PM

Sunday: 8AM to 2PM

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