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?

If ‘Yes’ please give details.

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

If ‘Yes’ please give details.

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

If ‘Yes’ please give details.

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

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?

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

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

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

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

Structural Health

Are any of these injuries aggravated by exercise?

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?

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.