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Physical Activity Readiness Questionnaire
First name:
Last name:
Address Line 1:
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County:
Post Code:
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email:
DOB (dd/mm/yyyy):
Do you suffer Back / Shoulder / Hip / Knee Pain?
Yes
No
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Do you suffer any joint conditions ie Arthritis?
Yes
No
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Do you suffer High or Low Blood Pressure?
Yes
No
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Do you suffer from Osteopenia or Osteoporosis?
Yes
No
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Have you recently given birth?
Yes
No
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Have you recently had any injuries or operations?
Yes
No
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Are you currently taking any medication?
Yes
No
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Any other relevant information
By checking this box and typing my name I agree to the above statement, and certify that the information I have provided in this form is accurate and applicable to me.
I agree
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