Physical Activity Readiness Questionaire

Regular physical activity is fun and helps form part of a healthy lifestyle.

You complete this form and, if necessary, check with your doctor before embarking on any new activity programme.

Please read and answer the questions below carefully. All information you provide will be treated with the strictest of confidence and destroyed at the end of the course.

1. *Has your doctor ever said you have a heart condition?

YES     NO

2. *Do you feel pain in your chest when you do any physical activity?

YES     NO

3. *In the past month have you had chest pain when you were not doing physical activity?

YES     NO

4. *Do you lose your balance because of dizziness or do you ever lose consciousness?

YES     NO

5. *Do you have any back or joint pain that could be made worse by an increase in physical activity?

YES     NO

6. *Do you suffer from raised blood pressure?

YES     NO

7. *Do you suffer from diabetes?

YES     NO

If you have answered YES to any of these questions, please provide details below:

If you answered YES to any questions numbered 1-7 it is required that you check with your doctor prior to taking part in this programme and that they provide evidence to us of this, or you may be able to sign a disclaimer - get in touch.

8. *Do you have asthma?

YES     NO

If YES how is it controlled?

A few additional questions

*How did you find out about the RPAC Couch to 5K Programme?

Our communication with the participants uses a WhatsApp group which is deleted afterwards. We add participants to the group using their mobile phone number.

*Are you happy being added to the WhatsApp group?

YES     NO

We occasionally take group photographs during the programme to be placed on our platforms. If you are not happy with this we will do our best to ensure that you are aware when a photo is being taken.

*Are you happy with group photographs?

YES     NO

If you'd like to inform us of anything else regarding your participation with the programme please add it below.

Disclaimer
I accept that Reigate Priory Athletic Club will not be held liable for any injury, loss or illness resulting from my participation in this programme or parkrun event and that I attend at my own risk.
By agreeing and dating this form I am confirming that the information I have given is correct and I am participating in the programme on a voluntary basis.

*Signed :

(Participant - type your full name)

*Date :

(Type today's date)