Rotherham Institute for Obesity

                                           

RIO Pre-Activity Readiness Questionnaire (PAR-Q)  

and Disclaimer 

 

This information has to be read and understood 

 by all patients wishing to use the on-site gym facilities. 

 

Regular physical activity is fun and healthy, and many people are becoming more active every day.   

Physical activity is not only good for cardiovascular fitness, but any regular physical activity can raise your Metabolic Rate and assist in accelerated and healthy weight loss.   

Becoming more active is very safe for most people; however, some people should consult their Doctor before increasing the amount of exercise they take. 

 

If you are planning to become much more physically active than you are now, start by answering the 7 questions below. 

If you are over 70 years of age, and you are not used to much in the way of exercise, consult your Doctor before completing this form. 

If you are between the ages of 18 and 70, and answer YES to any of the questions below, you should consult your Doctor before you start on an exercise programme. 

 

Yes No 

  □    □     Has your Doctor ever said that you have a heart condition and that you should limit your    physical  activity to that recommended by a Doctor? 

      Do you feel pain in your chest when you undertake physical activity? 

      In the past month, have you had chest pain when NOT undertaking physical activity? 

      Do you lose balance because of dizziness or do you ever lose consciousness? 

      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? 

      Is your Doctor currently prescribing drugs for high blood pressure or a heart condition? 

      Do you know of any other reason why you should not undertake physical activity? 

 

 

 

 

 

 

 

 

 

 

 


In signing this form I confirm that I have read, understood and completed this questionnaire.  I confirm the above answers are true and accurate to the best of my knowledge and belief.  I undertake to notify a member of the RIO staff at once if any of the answers to the above questions change.  I agree not to use any item of exercise equipment without receiving full instructions beforehand, in its use, from the RIO Exercise Therapist.  I am aware that physical activity can be hazardous and there is a risk involved. 

 

 

I have read and understood the contents of this Questionnaire and Disclaimer. 

 

 

Patient Name…………………………………Signature…………………………Date…..…..