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PRQ Information

Terms & Conditions

By submitting this form you agree and understand that any participation in this programme is completely voluntary and you may withdraw from the prescribed exercises at any time. You also confirm that you understand that exercise involves inherent but unlikely risk of injury and in extreme circumstances the possibility of death.

By submitting this form below you confirm that you have answered honestly all of the pre-exercise medical questions and release Keith Molloy from any liability with respect to any damage or injury which you may suffer whilst exercising.

Risk Stratification

More Than 1 Primary Risk Factor Individuals with more than 1 primary risk factor should delay becoming more active until they have sought medical clearance from a G.P

More Than 2 Secondary Risk Factors Those with more than 2 secondary risk factors should also delay becoming more physically active until they have sought medical clearance from a G.P

Name*
Address
Gender
Age
Height
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity unless recommended by a doctor?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 when not doing physical activity?Yes   No  
4. Do you lose balance because of dizziness or do you ever lose consciousness?Yes   No  
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes   No  
6. Is your doctor currently prescribing you drugs (for example water pills) for your blood pressure or heart?Yes   No  
7. Do you know any other reason why you should not do physical activity?Yes   No  
Primary Risk Questions

1. Are you a cigarette smoker or one who has quit within the last 6 months?

Yes   No  
2. Do you have a history of heart within your family or has a male first degree relative under 55 or a female first degree relative 65 suffered from a heart attack, stroke or sudden death?Yes   No  
3. Do you suffer from high blood pressure (140/90mm hg) and has this been confirmed with measurements on 2 separate readings? Yes   No  
4. Are you as obese? If so please indicate the method used to assess your obesity (BMI,% BF,hips-waist etc)Yes   No  
Secondary Risk Questions

5. Do you suffer from diabetes? If so indicate the type & whether you are insulin / glucagon dependent

Yes   No  
6. Are you sedentary? ( Do you do any sort of physical exercise like gardening, walking the dog, cycling, running etc ). Yes   No  
7. Do you suffer from high cholesterol (hypercholesterolemia)?Yes   No  
8. Are you a male over the age of 45 or a female over the age of 55 who has previously been sedentary?Yes   No  
*

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