ISLE OF WIGHT FITNESS – HEALTH QUESTIONNAIRE  

Name                                                                     Emergency Contact

Email                                                                      Birthday

Would you like to be added to the mailing list to receive class updates/cancellations? 

YES/NO

 

For most people, physical activity should not pose a problem or hazard. The PAR-Q has been designed to identify the small number of people for whom physical activity might be inappropriate or for those who should seek medical advice concerning the type of activity most suitable for them.  

​

Photo & Video Consent: I understand that during exercise classes, Helen may take photographs or videos for promotional purposes (e.g., social media, website, flyers). I consent to being photographed and for my image to be used for these purposes. 

YES/NO

 

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

YES/NO

Do you ever feel chest pain when you do physical activity? 

YES/NO

Are you currently prescribed any medication for blood pressure, diabetes or a heart condition? 

YES/NO

Do you have asthma or exercise induced asthma? 

YES/NO

Do you often feel faint, have spells of severe dizziness or have you ever lost consciousness? 

YES/NO

Do you have a bone or joint problem that could be made worse by exercise? 

YES/NO

Do you know of ANY other reason why you should not do physical activity? YES/NO  

YES/NO

 

If you answered YES to any of the above, you should ensure your GP has confirmed that it is safe for you to become physically active at this current time and in your current state of health. By signing this form, you confirm that your doctor has given specific clearance to undertake this class. 

 

If the answer to all questions is ‘NO’ we can assume it is reasonably safe for you to participate in physical activity gradually building up from your current ability level

If your health changes in any way you NEED to tell your instructor before you start your next class. 

 

INFORMED CONSENT  

Exercise can have great health benefits and improve cardiovascular fitness, muscle strength, endurance and flexibility. However, exercise can contain certain risks such as muscle strains, joint sprains, aches, pains and injury. Your instructor will provide different levels for the exercises to minimise these risks, however, if at any time during the exercise programme you feel pain, discomfort or you feel unwell you must stop immediately. 

 

 I confirm that I am voluntarily engaging in exercise knowing that my participation involves some risk of injury or even death. I understand that the instructor will provide different levels of the exercises and it is my responsibility to ensure I choose the appropriate level for my current ability. 

 

I participate at my own risk and accept full responsibility for the risk of any injuries or damages that may occur during or following my lesson. 

 

I have read, understood, and honestly completed the questionnaire.   

Signature                                                                      Emergency Contact Details: 

Print name                                                                    Date                                                           

 

Data protection information  

Your personal information requested to allow us to ensure safe practice. The information you provide will be kept securely and is not shared with any third parties. Although regular updates will be requested, unless otherwise instructed by you, this form will be kept for 6 years.