PARQ Form | Celtic Leisure

Your Details

Name(Required)

First Last

Date of birth(Required)

Day

Month

Year

Gender(Required)

Phone(Required)

Email(Required)

Height(Required)

Weight(Required)

Emergency Contact Details

Emergency Contact Name(Required)

First

Emergency Contact Phone(Required)

Preferred site(Required)

Health Questionnaire

Is there any history of heart disease in anyone in your family under the age 50?(Required)

Yes

Have you ever suffered from heart disease, high blood pressure or any other Cardio-vascular problem?Have you ever suffered from heart disease, high blood pressure or any other Cardio-vascular problem?(Required)

Yes

If yes, what:(Required)

Do you have a bone or joint problem that could be made worse by physical exercise?(Required)

Yes

Are you pregnant or have you had a baby within the last six months?(Required)

Yes

Do you have Diabetes Mellitus?(Required)

Yes

Have you any medical condition which you think might interfere with your participation in an exercise programme?(Required)

Yes

If yes, what:(Required)

Are you taking any medication at the moment?(Required)

Yes

If yes, what:(Required)

Are you recovering from a recent illness or operation?(Required)

Yes

If yes, what:(Required)

Have you ever had chest pains?(Required)

Yes

Do you ever feel faint or have spells of dizziness?(Required)

Yes

Are you a newcomer to exercise and aged over 35 (male) or 45 (female)?(Required)

Yes

Do you smoke?(Required)

Yes

IF YOU HAVE ANSWERED YES TO ONE OR MORE OF THE ABOVE QUESTIONS, your Instructor will need more information. You may also need to get clearance from your doctor before starting any exercise programme.

If you have or have ever had any of the following, Please tell your Instructor Prior to the Session(Required)

Neck pain

Knee pain

Back pain

Ankle pain

Muscular pain

Arthritis

Asthma

Cramps

Diabetes

Exercise History

What exercise have you been doing recently?(Required)

What was the workout intensity?(Required)

Hard

Medium

Light

How long have you been exercising (Months/Years)(Required)

How often have you been exercising (eg: 1 x per week)(Required)

Celtic Leisure Gym Code of Conduct & Consent

No kit to be brought into gym area.
Please use lockers provided (no items are to be stored in lockers over night).
Appropriate footwear and clothing to be worn at all times.
Shouting, swearing, grunting, and loud noises will not be tolerated.
Do not drop weights on floor.
No muddy footwear to be worn.
No activities to be undertaken other than those deemed to be appropriate and acceptable by management and staff.
Please clean your training area after use.
Please respect other members using the gym.
Please return all equipment after use.
No food or hot drinks allowed.
Seek assistance if training alone, when trying new exercises or for additional guidance.
Always exercise within your own limitations.

CL reserves the right to refuse entry / withdraw membership in the event of failure to comply with the centre regulations.

Health and Safety
Safe use of equipment including getting on/off and emergency stop procedure

Consent(Required)

I have read and understood the Gym Code of Conduct and agree to abide by the terms and general conditions of use as outlined above.

Consent(Required)

I confirm have watched the Celtic Leisure Induction Video

Consent(Required)

GDPR Consent (Please tick) I consent to my data being stored by Celtic Leisure for communication purposes.

Acknowledgement

By Clicking Submit I acknowledge that I have not withheld any relevant information relating to my present health status. I understand it is my responsibility to inform my instructor of any future changes in health that may occur or of any problems I experience when exercising.

Whilst safe and effective exercise may produce many health benefits, it is important to realise there is also the low possibility of exercising causing some difficulties. It is recommended that to avoid any risk, you start to exercise gently and gradually build up your fitness. Initially you may experience some local discomfort and slight fatigue, but as the programme continues, they should disappear. I understand that there may be a small risk in starting an exercise programme and I undertake to inform my Instructor if I experience any problems when exercising.