CIMSPA Certified Personal Trainer, Pre/Post Natal and Nutritional coach

Motivasi ParQ

Physical Activity Readiness Questionnaire
(To be completed after booking a package option)

Purpose: PAR-Q is designed to show the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. If you have any issues completing this form, please use the contact detail below.

E-mail: info@motivasi.co.uk

Name*

This field is mandatory

Date of Birth*

This field is mandatory

E-mail*

This field is mandatory

The e-mail address is invalid

Gender*

This field is mandatory

1.Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?*

This field is mandatory

2.Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*

This field is mandatory

3.Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?*

This field is mandatory

4.Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*

This field is mandatory

5.If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?*

This field is mandatory

6.Do you have any other conditions that may require special consideration for you to exercise?*

This field is mandatory

7.Family history of heart disease (e.g. stroke, heart attack)?*

This field is mandatory

8.Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months? *

This field is mandatory

9.Have you been told that you have high blood pressure?*

This field is mandatory

10.Have you been told that you have high cholesterol/ blood lipids?*

This field is mandatory

11.Have you been told that you have high blood sugar (glucose)?*

This field is mandatory

12.Are you currently taking prescribed medication(s) for any condition(s)? *

This field is mandatory

13.Have you spent time in hospital (including day admission) for any condition/illness/injury during the last 12 months? *

This field is mandatory

14.Are you pregnant or have you given birth within the last 12 months? If so please also complete the Post Natal ParQ. *

This field is mandatory

15.Do you have any diagnosed muscle, bone, tendon, ligament or joint problems that you have been told could be made worse by participating in exercise?*

This field is mandatory

I agree that this data will be stored and processed for the purpose of assessing your ability to perform certain fitness exercise. Therefore personalising your training requirements to achieve your goals. I am aware that I can revoke my consent at any time.*

This field is mandatory

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Motivasi ParQ

Physical Activity Readiness Questionnaire (To be completed after booking a package option)

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Physical Activity Readiness Questionnaire
(To be completed after booking a package option)