READINESS QUESTIONNAIRE

 

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Readiness Questionnaire

 

Indemnity

 

 

 

Please complete the Fitness Activity Readiness Questionnaire (FAR-Q), providing details of any of the injuries, illnesses, health conditions, disabilities and dysfunctions you currently have or may have had, and which will affect your ability to take part in a fitness program.

 

1.

Do you have a regular aerobic fitness training program?"

 

If yes provide details of the nature, frequency, intensity and duration of your exercise program.

 

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Yes o

No o

 

 

 

2.

Do you have a regular and systematic strength training program?

 

If yes provide details of the nature, frequency, intensity and duration of your exercise program.

 

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..........................................................................................

 

Yes o

No o

 

 

 

3.

Have you ever had heart disease or dysfunction?

 

If yes provide details.

 

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Yes o

No o

 

 

 

4.

Are you currently on medication for high blood pressure?

Yes o

No o

 

 

 

5.

Are you currently on medication for an elevated level of blood cholesterol?

Yes o

No o

 

 

 

6.

Are you currently on medication for adult onset diabetes?

Yes o 

No o

 

 

 

7.

Do you suffer from asthma in a way which would prevent you from from being involved in continuous exercise of a vigorous and strenuous nature?

Yes o

No o

 

 

 

8.

Do you have any bone or joint problems which would prevent you from being involved in continuous exercise of a vigorous and strenuous nature?

Yeso

No o

 

 

 

9.

Do you suffer from epilepsy?

Yes o

No o

 

 

 

10.

Do you suffer from fainting/dizzy spells?

Yes o

No o

 

 

 

11.

Are you currently on medication for depression?

Yes o

No o

 

 

 

12.

Is there anything at all about your health that you feel you should disclose before you participate in an assessment of your physical fitness. If yes, provide details.

 

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Yes o

No o

     

 

……………………………………...............                 ……../……../……..

             Signed                                         Date

 

 

 

 

Miller Health Pty Ltd

7 Salvado Place, Stirling (Canberra) ACT 2611 Australia

61 2 6288 7703