Health Intake Form
This form must be completed PRIOR to participating in any
Peg Family Fitness class. 
** If you require assistance in completing this form please contact Peg Family Fitness. Steph will be happy to help you! **

Par-Q: Physical Activity Readiness Questionnaire

Regular physical activity is fun and the health benefits are clear. More people should engage in physical activity every day of the week. Engaging in physical activity is very safe for most people. However, some people should check with their doctor before they start becoming more physically active.

 

This questionnaire will tell you if you need to consult a doctor before becoming more physically active.

 

If you are pregnant, please notify Peg Family Fitness. You will be given a different form to fill out. 
 

Common sense is your best guide when answering these questions. Please read the questions carefully and answer each one honestly: check YES or NO

1) Has your doctor ever said that you have a heart condition OR high blood pressure?
2) Do you feel pain in your chest when you do physial activity?
3) Do you lose balance because of diziness OR have you lost consciousness in the past 12 months?
4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
5) Are you currently taking prescribed medication for a chronic medical condition?
6) Do you currently have (or have had in the past 12 months) a bone, joint, or soft tissue (muscle, tendon, ligament) problem that could be made worse by becoming more physically active?
7) Has your doctor ever said that you should only do medically supervised physical activity?

If you answered YES to any of questions 1-7, you should seek further advice before becoming more physically active. Please speak with your doctor and/or contact Peg Family Fitness about completing the ePARmed-X form, a more in-depth online screening tool. You may be able to do any activity you want, including participating in Peg Family Fitness classes, or you may need to restrict your activities.

If you answered NO to all of questions 1-7, you can be reasonably sure that you can start becoming more physically active! It is advised that you begin slowly and build up gradually.

You should delay becoming more active if you are not feeling well because of a temporary illness (such as a cold or a fever). Please wait until you feel better. If you are pregnant please talk to your doctor or contact Peg Family Fitness for a more in-depth screening tool prior to participation.

Note: If your health changes so that you answer YES to any of questions 1-7, please consult your doctor and fitness professional. 

By initialling below I acknowledge that I have read, understood, and completed to the best of by knowledge the questionnaire above. I acknowledge that this questionnaire is valid for 12 months from the date it is initialled and becomes invalid if my condition changes. Peg Family Fitness may keep a copy of this form for their records. 

Thanks for submitting!