Consent Form

"*" indicates required fields

1Basic Info.

2PAR-Q FORM(PHYSICAL ACTIVITY READINESS QUESTIONNAIRE)

Name*

Form Filling Date*

DD slash MM slash YYYY

Have your doctor ever said that you have a heart condition and that you should only do physical activity/exercise recommended by a doctor?*

Yes

No

Is there any history of heart disease in your family?*

Yes

No

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

Yes

No

Do you lose your balance before of dizziness or do you ever lose consciousness?*

Yes

No

Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity*

Yes

No

Do you suffer from any of following asthma; diabetes; epilepsy; high blood pressure?*

Yes

No

Do you have any other medical or physical condition(such as cancer or osteoporosis)?*

Yes

No

Do you have any current injury or conditions, and if so are they being treated by a doctor or other health professionals such as a physiotherapist?*

Yes

No

Do you know of any other reason why you should not do physical activity or exercise?*

Add your signature*

Max. file size: 2 MB.

Consent*

I agree to the RULES & REGULATIONS.*

CAPTCHA

B-Square Corporate House, C-2, Mango Garden City Road, Near Croma, Thaltej, Ahmedabad, Gujarat-380054