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Ballymena, Northern Ireland

Call Mark: 07599 467 637
Mark@TheRawGym.co.uk

PARQ & Medical Questionnaire

THIS FORM MUST BE COMPLETED BEFORE YOUR 1ST VISIT

First Name

Email Address

House number/name

Town/city

Last Name

Phone

Street

Postcode

Date of Birth mm/dd/yyyy

weight in KG (if known)

Height in cm

Have you been hospitalized in the last 12 months?

No

Yes

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

Are you currently taking medication

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete, I also declaire that i will follow all safety and security instructions, whether supervised or unsupervised during exercise.

thank you for completing the PARQ - train safetly and enjoy your resutls.

The Raw Gym Ballymena
201 Carniny Road, Ballymena, BT43 5NJ
Mark McIntyre, REPS Member ID: R0055691

www.therawgym.co.uk, 07599467637

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