Physical Activity Readiness Questionnaire

Youth Zone Member

Member First Name

Member Last Name

Member Date of Birth

DD/MM/YYYY

Physical Activity Readiness

Does the young person:

Have a heart condition?

Yes

No

Feel chest pain at rest or during physical activity?

Yes

No

Lose balance due to dizziness or faint?

Yes

No

Have a bone or joint problem?

Yes

No

Experience shortness of breath?

Yes

No

Take blood pressure medication?

Yes

No

Any other reason the member should not exercise?

Yes

No

Thanks for confirming.

The member must complete an induction at the Youth Zone before using the gym, and before doing some other physical activities.

If the member's health changes, it is important that you tell the Youth Zone.

Please tell us more:

Thanks for telling us about the member's physical activity readiness.

Because of the answers you gave us, we may need more information before the member can complete an induction to use the gym or take part in some other physical activities.

The good news is the member can still enjoy lots of our other activities in the meantime!

If the member's health changes, it is important that you tell the Youth Zone.

I am the

Parent/Guardian Name

Relationship to Young Person

Phone

For further information about how we process your personal information, who we may share it with, and your rights, please read our Privacy Notice.

Youth Zone