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PARQ
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Name
*
First
Last
Date of Birth
*
Height
*
Weight
*
Email
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
In case of Emergency Contact
*
Relationship to ICOE
*
GP Practice
*
Have you ever had a exercise stress test?
*
Yes
No
Don't Know
Do you take any medications?
*
Yes
No
If Yes, please give details:
*
Have you recently been hospitalised?
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Yes
No
If Yes, Please give details:
*
Do you smoke?
*
Yes
No
Are you pregnant?
*
Yes
No
Do you drink alcohol more than 3 times a 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
High cholesterol
*
Yes
No
Diabetes
*
Yes
No
Have you or your parents or siblings who, prior to age 55 had:
A heart attack?
*
Yes
No
A stroke?
*
Yes
No
High blood pressure
*
Yes
No
High cholesterol
*
Yes
No
Known heart disease
*
Yes
No
Rheumatic heart disease
*
Yes
No
A heart murmur
*
Yes
No
Chest pain with exertion
*
Yes
No
Irregular heart beat or palpitations
*
Yes
No
Light-headedness or suffer faints
*
Yes
No
Unusual shortness of breath
*
Yes
No
Cramping pains in legs or feet
*
Yes
No
Emphysema
*
Yes
No
other metabolic disorders (thyroid, kidney, etc.)?
*
Yes
No
Epilepsy
*
Yes
No
Asthma
*
Yes
No
Back pain
*
Yes
No
Other joint pain
*
Yes
No
Muscle pain or an injury
*
Yes
No
If Yes, please give details
*
To the best of my knowledge, the information given is true.
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Home
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About
Adult's Taekwon-do
Children's Taekwon-do
Instructors
A.P.T.I.
D.B.S. (Child Protection)
The Gym
Metafit
MetaPWR
FAQ
Charity - Giving Back
Our Environmental Policy
Bookings Policy
Timetable
Contact
Store
Member Portal
News & Calendar
