Par-Q Form Name * First Name Last Name Email * Age * Gender * Female Male Do you or have you ever had a heart condition, high blood pressure or circulatory problems? * Y N Is there a history of heart disease in your family? * Y N Do you ever experience pain in your chest when exercising or at rest? * Y N Do you ever feel faint or suffer from dizzy spells? * Y N Do you experience back pain or do you have a joint condition (such as arthritis) that could be exacerbated by physical activity? * Y N Do you have asthma? * Y N Do you have Diabetes? * Y N Do you suffer from epilepsy? * Y N Have you had surgery or a medical procedure in the past year that may affect your physical activity? * Y N Are you currently taking any prescribed medications? * Y N Are you aware of any other condition or injury that may give reason to modify your exercise programme? * Y N For women: Are you pregnant? * Y N N/A Please provide any additional info if necessary: Waiver statement I have read and agree to the waiver statement * Yes Today's Date * MM DD YYYY All done & thank you. See you in class!