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Participant Activity Readiness Questionnaire
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This field is for validation purposes and should be left unchanged.
Forename
*
Surname
*
Contact Number
*
Email Address
*
Gender
Male
Female
Other
Date of Birth
*
Emergency Contact
Name:
*
Relationship:
*
Contact number
*
Participant Activity Readiness Questionnaire
1. Blood pressure: (if known) - mmHg
2. How would you describe your current level of fitness?
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Unfit
Moderately Fit
Fit
Trained
3. Are you currently a smoker?
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Yes
No
4. Do you drink alcoholic drinks?
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Yes
No
If yes do you have
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The occasional drink
A drink everyday
More than one drink a day
5. Do you suffer, or have suffered from?
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Asthma (within the last 2 years)
Diabetes
Bronchitis
Epilepsy
Any form of heart complaint
Dizziness or fainting
None of the above
Please provide some detail
6. Is there any history of heart disease in your family?
*
Yes
No
Please provide some detail.
7. Do you currently have any form of muscle or joint injury that may be aggravated by exercise?
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Yes
No
Please provide some detail.
8. Have you had any cause to suspend normal activity in the last two weeks?
*
Yes
No
Please provide some detail.
9. Are you currently taking any form of medication?
*
Yes
No
Please provide some detail.
10. In the past month, have you had any chest pain when you were not doing physical activity?
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Yes
No
Please provide some detail.
11. Do you feel pain in your chest when you do physical activity?
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Yes
No
Please provide some detail.
12. Finally, do you know of any other reason that may prevent you from participating in physical activity?
*
Yes
No
Please provide some detail.
Signature
Your Name
Your Name
Your Name
Your Name
