Physical Activity Readiness Questionnaire

Please fill in the following questionnaire before undertaking any trekking activities:

First Name *

Last Name *

Phone *

Email *

Date of Birth *

Unit Number

Street Address

Country

Postal

1. Has your doctor ever said that you have a heart condition & that your physical activities should be restricted/monitored? * Yes No

2. Do you feel pain in your chest when you do physical activity? * Yes No

3. In the past month, have you had chest pain while you were 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 bone or joint problems that may worsen by a change in your physical activities? * Yes No

6. Is your doctor prescribing you drugs for a heart condition or one that affects blood pressure? * Yes No

7. Do you know of any reason why you should not increase your physical activity? * Yes No

If you answer is YES to one of more questions:

Please consult a doctor first before taking part in any of the programme.

You may be able to do any activity you want as long as you start slowly and build up gradually or you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activities you wish to participate in.

If you are not feeling well because of a temporary illness such as cold or fever, wait until you feel better before exercising.

If you are or may be pregnant, talk to your doctor before you start beginning an exercise program.

Adapted from PAR-Q - Physcial Activities Readiness Questionaire
If you answered yes to one or more questions, we recommend a physician's approval certificate before commencing your training.
A copy of this form needs to be taken to your doctor, as you may need to restrict the specific type of exercise that you do.

Emergency Contact Information

Emergency Contact Person *

Emergency Contact Phone *

I have understood the questions above and my answers are true and correct. I have provided full disclosure of any other medical or physical problems or issues that Amazing Trekkers Club (ATC) should know about before commencing an exercise program and /or undertaking a trek. or I accept that I will not have any claim against ATC or my instructor for any illness, injury or adverse change in medical conditions arising directly or indirectly from any exercise program carried out. I also agree if I do have any changes in my health conditions I will inform ATC and complete this form again.

I agree to the terms and conditions *

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