PAR-Q – Isabel Dawkes Health

PAR Q

Please carefully read and fill out the below form, you will then be able to sign with your signature electronically, this is binding in the same way that an ink signature would be.

Name

Medical ConditionsPlease let me know about any medical conditions I should be aware of (this includes long standing illness (mental/physical), disability, or injuries), and any implications for exercise you can and cannot perform:

MedicationsAre you taking any medications for your physical health?

Please select any of the following that apply to you

shortness of breath with light exertion

pain, tightness, pressure or heaviness in your chest

regular and unexplained pain in the abdomen, shoulder or arm

severe dizzy spells or episodes of fainting

regular lower limb pain from walking, that is relived by rest

palpitations or irregular heartbeat

currently pregnant or given birth in the last 6 months

Please use the space below to provide any more detail that you feel is relevantLeave blank if you have nothing further

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