PAR- Q

Client Name

Date of Birth

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Email

Phone Number

Area CodePhone

As your child is to be a client of Lizzie Fitness (Lizzie Fluke), would you please complete the following health questionnaire.

Your cooperation is greatly appreciated.

Any information contained here in will be treated as confidential

Has your child had a major illness or injury in the last 5 years?

YesNo

If ‘Yes’ please give details.

Does your child receive treatment for any medical condition or allergies?

YesNo

If ‘Yes’ please give details.

Is your Doctor currently prescribing any medication for your child’?

YesNo

If ‘Yes’ please give details.

Does your child have uncontrolled asthma (i.e. asthma that is not easily controlled by an inhaler?

YesNo

If ‘Yes’ please give details.

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

YesNo

Please indicate if your child has experienced any of the following symptoms.

Ever have pain, pressure, heaviness or tightness in the chest area?Ever get unusually short of breath with very light exertion?Regularly have unexplained pain in the abdomen,shoulders or arm?

Please indicate if your child has ever experienced any of the following symptoms.

Ever have severe dizzy spells or episodes of fainting?Regularly get lower leg pain during walking that is relieved by rest?Ever experience palpitations or irregular heartbeats?

Does your child lose balance because of dizziness or has your child ever lost consciousness?

YesNo

Does your child have a bone or joint problem that could be made worse by a change in their physical activity participation?

YesNo

Structural Health

Are any of these injuries aggravated by exercise?

YesNo

Please indicate any other health and well-being problems, your child may suffer from which has not already mentioned.

Does your child have any impairments or require any assistance to take part in activities?

YesNo

If ‘Yes’ please give details.

I can confirm that the above information is correct at the time of completing this questionnaire

Please Note: If your child's health changes so that you answer YES to any of the above questions, please complete a new health questionnaire. Consult with your doctor / medical professional regarding the level of physical activity your child can conduct.*

Terms and Conditions