Physical activity readiness questionnaire for children Parents Name * House Number * Street * Town * Postcode * Contact Number * Email * number of Children * one two three four First child's name * First child's D.O.B * First Child's Age * 4567891011121314 Health QuestionsDoes your child have or have they ever experienced the following: High or low blood pressure * Yes No Elevated blood cholesterol * Yes No Diabetes * Yes No Chest pains brought on by physical exertion * Yes No Childhood epilepsy * Yes No Dizziness or fainting * Yes No A bone, joint, or muscular problems with arthritis Yes No Asthma or other respiratory problems * Yes No Any sustained injuries or illness * Yes No Any allergies Yes No Is your child taking medication? * Yes No Has your doctor ever advised your child not to exercise? Yes No Is there any reason not mentioned above why physical activity may not be suitable for your child? * Yes No Please provide details to any of the question above you answered yes to Second Child's Name * Second child's D.O.B * Second child's age * 4567891011121314 Health QuestionsDoes your child have or have they ever experienced the following: High or low blood pressure * Yes No Elevated blood cholesterol * Yes No Diabetes * Yes No Chest pains brought on by physical exertion * Yes No Childhood epilepsy * Yes No Dizziness or fainting * Yes No A bone, joint, or muscular problems with arthritis Yes No Asthma or other respiratory problems * Yes No Any sustained injuries or illness * Yes No Any allergies Yes No Is your child taking medication? * Yes No Has your doctor ever advised your child not to exercise? Yes No Is there any reason not mentioned above why physical activity may not be suitable for your child? * Yes No Please provide details to any of the question above you answered yes to Third Child's Name * Third child's D.O.B * Third child's age * 4567891011121314 Health QuestionsDoes your child have or have they ever experienced the following: High or low blood pressure * Yes No Elevated blood cholesterol * Yes No Diabetes * Yes No Chest pains brought on by physical exertion * Yes No Childhood epilepsy * Yes No Dizziness or fainting * Yes No A bone, joint, or muscular problems with arthritis Yes No Asthma or other respiratory problems * Yes No Any sustained injuries or illness * Yes No Any allergies Yes No Is your child taking medication? * Yes No Has your doctor ever advised your child not to exercise? Yes No Is there any reason not mentioned above why physical activity may not be suitable for your child? * Yes No Please provide details to any of the question above you answered yes to Fourth child's name * Fourth child's D.O.B * Fourth child's age * 4567891011121314 Health QuestionsDoes your child have or have they ever experienced the following: High or low blood pressure * Yes No Elevated blood cholesterol * Yes No Diabetes * Yes No Chest pains brought on by physical exertion * Yes No Childhood epilepsy * Yes No Dizziness or fainting * Yes No A bone, joint, or muscular problems with arthritis Yes No Asthma or other respiratory problems * Yes No Any sustained injuries or illness * Yes No Any allergies Yes No Is your child taking medication? * Yes No Has your doctor ever advised your child not to exercise? Yes No Is there any reason not mentioned above why physical activity may not be suitable for your child? * Yes No Please provide details to any of the question above you answered yes to Date Completed * Submit ParQ
