wendywhearity.com
Home
About
Coaching
Race history
Speaking
Testimonials
Contact
wendywhearity.com
Home
About
Coaching
Race history
Speaking
Testimonials
Contact
PAR Q Form
Wendy Whearity
Remote sports coaching
Name
*
First Name
Last Name
Email
*
Mobile phone
*
Height
*
Weight
*
DOB
*
MM
DD
YYYY
Emergency contact name/relationship
*
Emergency contact number
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
GP name
*
GP address
*
GP phone
*
Do you take any medications on a regular basis?
*
Yes
No
Please list medications and reason for taking
Have you recently been hospitalised?
*
Yes
No
If yes please explain
Do you smoke?
*
Yes
No
Are you pregnant?
*
Yes
No
Do you drink alcohol more than 3 times per week
*
Yes
No
Is your stress level high
*
Yes
No
Are you moderately active on most days of the week?
*
Yes
No
Do you have high blood pressure
*
Yes
No
Don't know
Do you have high cholesterol?
*
Yes
No
Don't know
Do you have diabetes?
*
Yes
No
Don't know
Have parents or siblings below the age of 55 had a heart attack?
*
Yes
No
Don't know
Have parents or siblings below the age of 55 had a stroke?
*
Yes
No
Don't know
Have parents or siblings below the age of 55 had high blood pressure?
*
Yes
No
Don't know
*
By ticking this box you confirm all the information given above is correct to the best of your knowledge and if any personal or medical information should change in the future you will advise me immediately.
*
Data Protection: All information in this form is required for the purposes of an initial health assessment and as part of an ongoing training schedule. Your personal data will never be shared with any third parties. For more information on data protection and/or privacy, please get in touch with me through the contact form. By ticking this box, you acknowledge the above statement, and give permission for your data to be stored by me for the duration of our coaching contract.
I agree to the Data Protection Statement as outlined above.
Your par-q form has been submitted. Thank you!