PARQ FORM

Young Person’s ‘Physical Activity Readiness’ Questionnaire

Dear Parent / Guardian,

There are many health benefits to be gained when children and young people exercise regularly. It is
sensible however to consider their health status prior to commencing a physical exercise programme. This
questionnaire aims to identify your child’s health status so that we can provide exercise advice and avoid any
risk of injury or illness.

Young Person’s Registration Information

First Name: …………………………………………Surname: ……………………………………………..

Address: ……………………………………………………………………………………………………….

………………………………………………………………………………………………………………….

……………………………………………………… Postcode: ……………………………………………

Home No: ………………………………………… Mobile No: …………………………………………..

Gender: Male / Female (please circle) Date of Birth: ………………………………………..

The following questions relate to the health of the young person. Please read the questions carefully and
provide a correct answer by circling Yes or No. Where necessary, please provide details.

Details

Has a doctor ever diagnosed your child with a

Yes No
heart condition?
Has your child recently had chest pains during
Yes No
or after exercise?
Does your child ever feel faint or have spells of
Yes No
severe dizziness?
Is your child currently receiving treatment or
Yes No
medication for high blood pressure?
Is your child currently receiving treatment or
Yes No
medication for any other condition?
Has your child broken any bones in the past six
Yes No
months?
Does your child suffer from any bone or joint
Yes No
problems which exercise may aggravate?
Does your child suffer from epilepsy or chronic
Yes No
asthma?
Is your child diabetic? If yes, is the diabetes
Yes No
type 1 or Type 2?
Has your child undergone any recent surgery?
Yes No
Is there any other reason which has not been
mentioned that may affect your child if they Yes No
took part in physical activities?

Continued Overleaf

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It is important to note that if you have answered “YES” to any of the above questions, there may be
restrictions on your child’s ability to participate in exercise programmes. If you are unsure of any of the
information you have provided we strongly advise that you consult with your Doctor before allowing your
child to begin any exercise programme.

Parent / Guardian Declaration

1. I confirm that the above answers are correct, at this point in time, to the best of my knowledge and
belief.

2. I will ensure that I inform the coach at once if any of the above information changes.

3. I agree that my child will abide by the rules of Queen’s Sport and follow the instructions of staff at all
times.

Signature: ……………………………………………………………………………………

Print Name …………………………………………………………………………………..

Relationship to Child ………………………………………………………………………..

Date……………………………………………………………………………………………

Coaches Signature …………………………………………………………………………..