Physical Activity Readiness Questionnaire
It is vital to answer all questions honestly and provide the relevant information concerning health in relation to physical activity.
Any optional questions will be noted with an asterisk *.
By signing you are agreeing to the responsibility for your own health, knowing the risks involved in exercise.
All of the following information will be safely stored physically in a lockable cabinet or online with password security which only I will have access to. It will be carefully destroyed when updated or the information becomes outdated.
Please click the relevant box (yes or no):
providing details below if you have ticked yes or are unsure
Medical History in Relation to Participation
Do you have any medical conditions that may affect your ability to participate?
Do you have any current or previous injuries that may impair certain activities?
Has your Doctor ever said that you have a bone or joint problem that has been aggravated by exercise or might be made worse with exercise?
Do you have high or low blood pressure?
Do you often feel faint or have spells of dizziness?
Are you currently taking any medication or receiving any treatment?
Do you have a disability or any sensory impairments?
(e.g. visual or auditory impairment)
Have you visited the GP within the past six months?
Are you or have you been pregnant in the past six months?
You & Your Goals
This is all about you. It’s a chance for me to understand your goals and how you want this opportunity to improve your life. It allows me to help you achieve your goals.
What would you class your activity level as*?
How often do you feel stressed*?
How would you describe your current diet and nutrition*?
(Nutrition and diet can have a big effect on energy levels, overall physical and mental health as well as your fitness goals. Being aware of this can help you start making changes, if needed, to attain your goals and improve both mental and physical function.)
Tick to Confirm
‘I can confirm that I have read, understood and answered honestly to all the above questions including any information that may affect my ability to participate. In signing this form, I acknowledge that there are risks involved with exercise including injury and the possibility of death. I am voluntarily engaging in these activities.’
(These risks can be minimised by providing as much detail on any medical issues and keeping me updated as to any changes in the condition of your health.)
Tick to Confirm
'I agree to my data being securely kept knowing that it will be properly disposed of to ensure confidentiality. No personal data will be disclosed unless to another professional with my consent (e.g GP for medical advice).