Pre-Activity Health Questionnaire (PAR-Q)
Igloo Wellness Centre Limited
Please complete this Pre-Activity Health Questionnaire (“PAR-Q”) in full before your first session at Igloo Wellness Centre. The information you provide helps us keep you safe. You must also tell us if anything in your answers changes after you have completed this form.
If you answer “Yes” to any question in Section 3, or tick any condition in Section 4, we may ask you to obtain written clearance from your GP or another qualified medical professional before participating in some or all activities.
This form is read alongside our Health, Safety & Participation Waiver and our Privacy Notice.
Section 1 — Your Details
Full name: ____________________________________________________________
Date of birth: ____________________ Today’s date: ____________________
Address: ______________________________________________________________________
Postcode: ____________________
Telephone: _________________________ Mobile: _________________________
Email: ____________________________________________________________
Emergency contact name: __________________________________________________
Emergency contact relationship: _________________________ Emergency contact number: _________________________
GP name and surgery: optional but recommended ____________________________________________________________
Section 2 — Activities You Intend to Participate In
Please tick all that apply:
- ☐ Sauna
- ☐ Ice bath / cold immersion
- ☐ Contrast therapy
- ☐ Yoga
- ☐ Mat pilates
- ☐ Reformer pilates
- ☐ Hot yoga
- ☐ Pregnancy, postnatal, baby, parent or family classes
- ☐ Other — please specify below
Other: ____________________________________________________________
Section 3 — General Health Questions
Please answer Yes or No to each of the following:
- Has a doctor ever said you have a heart condition, or that you should only do physical activity recommended by a doctor? ☐ Yes ☐ No
- Do you feel pain in your chest when you do physical activity? ☐ Yes ☐ No
- In the past month, have you had chest pain when you were not doing physical activity? ☐ Yes ☐ No
- Do you lose your balance because of dizziness, or do you ever lose consciousness? ☐ Yes ☐ No
- Do you have a bone or joint problem, for example back, knee or hip, that could be made worse by a change in your physical activity? ☐ Yes ☐ No
- Is your doctor currently prescribing drugs, for example water pills, for your blood pressure or a heart condition? ☐ Yes ☐ No
- Do you know of any other reason why you should not take part in physical activity? ☐ Yes ☐ No
- Are you currently pregnant? ☐ Yes ☐ No
- Have you given birth within the last 6 months, or are you currently breastfeeding? ☐ Yes ☐ No
- Have you had any surgery, illness or injury in the last 12 months that may affect your participation? ☐ Yes ☐ No
If you answered Yes to any of the above, please give brief details:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Section 4 — Medical Conditions Checklist
Please tick any of the following that apply to you, then provide brief details below.
Cardiovascular
- ☐ Heart disease, angina or history of heart attack
- ☐ Heart rhythm disorder, arrhythmia, AF, pacemaker or ICD
- ☐ High blood pressure — controlled
- ☐ High blood pressure — uncontrolled
- ☐ Low blood pressure
- ☐ History of stroke or TIA
- ☐ Raynaud’s phenomenon
- ☐ Varicose veins, DVT or circulation issue
Respiratory
- ☐ Asthma
- ☐ COPD or emphysema
- ☐ Other respiratory condition
Neurological
- ☐ Epilepsy or history of seizures
- ☐ History of fainting or blackouts
- ☐ Multiple sclerosis or similar
- ☐ Migraine — severe / frequent
Musculoskeletal
- ☐ Back or neck injury
- ☐ Joint condition or recent joint surgery
- ☐ Osteoporosis or osteopenia
- ☐ Arthritis or other chronic joint condition
- ☐ Pelvic floor or abdominal separation issue
Other
- ☐ Diabetes — Type 1 or Type 2
- ☐ Eating disorder — current or history
- ☐ Mental health condition that may affect participation
- ☐ Open wounds, recent skin infection or contagious skin condition
- ☐ Recent surgery — within last 6 months
- ☐ Allergies that we should know about
- ☐ Implanted medical device
- ☐ Other condition — please specify
Brief details of any ticked condition(s): ____________________________________________________________
______________________________________________________________________
______________________________________________________________________
Section 5 — Current Medication
Please list any prescription or non-prescription medication you are currently taking, and the condition it relates to:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Section 6 — Pregnancy and Postnatal
Are you currently pregnant? ☐ Yes ☐ No
If yes, weeks gestation: _______________ Expected due date: _________________________
Have you had clearance from your midwife or GP to participate? ☐ Yes ☐ No
Have you given birth in the last 6 months? ☐ Yes ☐ No
Have you had a 6-week postnatal check? ☐ Yes ☐ No
Note: sauna use, ice bath use and hot yoga are generally not recommended during pregnancy. We may require written clearance from your midwife or GP before you participate in any heat-, cold- or high-intensity activity.
Section 7 — Activity-Specific Considerations
7.1 Sauna and Heat Exposure
Do you have any history of overheating, heat intolerance or heat-related illness? ☐ Yes ☐ No
Are you currently dehydrated, fasting or feeling unwell? ☐ Yes ☐ No
7.2 Ice Bath and Cold Immersion
Have you used a cold immersion facility before? ☐ Yes ☐ No
Do you have any cold intolerance, Raynaud’s phenomenon, or any of the conditions listed at section 7 of the Waiver? ☐ Yes ☐ No
Do you understand that first-time users must be inducted and supervised by a member of staff? ☐ Yes ☐ No
7.3 Hot Yoga and Heated Classes
Have you participated in a heated class before? ☐ Yes ☐ No
Do you have any condition that may make heated exercise unsuitable? ☐ Yes ☐ No
7.4 Reformer Pilates
Have you used reformer pilates equipment before? ☐ Yes ☐ No
Do you have any condition that may make resistance-based exercise unsuitable? ☐ Yes ☐ No
Section 8 — Anything Else We Should Know
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Section 9 — Declaration and Acceptance
By signing below, I confirm that:
- the information I have provided in this PAR-Q is complete, true and accurate to the best of my knowledge;
- I will inform Igloo Wellness Centre promptly if my health, medication, pregnancy status or any other relevant information changes;
- I have read and accept the Igloo Wellness Centre Health, Safety & Participation Waiver, a copy of which has been provided to me;
- I have been given the opportunity to read the Igloo Wellness Centre Privacy Notice;
- I understand that Igloo Wellness Centre may, where it considers it necessary, ask me to obtain written medical clearance before participating in some or all activities;
- I understand that Igloo Wellness Centre may refuse, restrict or pause my participation in any activity where it reasonably considers that participation would be unsafe;
- I understand that failure to disclose relevant information may invalidate the protection that the Waiver, and any insurance, would otherwise provide.
Signature: __________________________________________________
Print name: __________________________________________________
Date: ______________________________
Section 10 — For Participants Under 18 Only
To be completed and signed by a parent or legal guardian where the participant is under 18 years of age.
Name of minor: __________________________________________________
Date of birth of minor: ______________________________
Name of parent / legal guardian: __________________________________________________
Relationship to minor: ______________________________
Telephone: ______________________________
I confirm that I have parental responsibility for the minor named above and authority to consent to their participation. I have completed this PAR-Q on the minor’s behalf and the information provided is complete, true and accurate to the best of my knowledge. I have read and accept the Waiver. I acknowledge that nothing in this PAR-Q or the Waiver purports to waive any right the minor may have to claim for personal injury.
Signature of parent / legal guardian: __________________________________________________
Date: ______________________________
Office Use Only
Reviewed by: ________________________________________
Date reviewed: ______________________________
Medical clearance required? ☐ Yes ☐ No
Restrictions on participation noted? ☐ Yes ☐ No
Notes: ______________________________________________________________________