UCD Better Bones Level 1
Exercise Programme
Registration Form
Please complete the Health Screening and Informed Consent Form
Name:
Date of Birth:
Address:
Contact Number:
E-Mail:
Emergency Contact:
Number:
Yes
No
Have you ever been told you have osteoporosis by a health professional / doctor?
Yes
No
Have you had a fracture in the last 3 years?
Yes
No
Are you currently exercising or physically active? Describe your current exercise programme / physical activity
If Yes, state when it happened and which bone was broken (e.g. hip, wrist, ribs, spine, etc.)
Have you had a fall in the last 12 months?
Yes
No
Has a doctor ever told you not to exercise?
Yes
No
Please tick the box if you would like to receive further information on future programmes
at UCD Sports Centre.
UCD Better Bones Exercise Programme is delivered by UCD Sport in partnership with UCD School of Public
Health, Physiotherapy and Sports Science and St Vincent’s University Hospital
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UCD Better Bones Level 1 Exercise Programme
Physical Activity Readiness Questionnaire (PAR-Q)
Regular physical activity is fun and healthy and increasingly people are starting to become more active every day. Becoming more
active is very safe for most people. However, if participation in the UCD Better Bones Level 1 Exercise Programme will cause you
to become substantially more active than you are at present start by answering the questions below. Regardless of your age the
PAR-Q will tell you if you should check with your doctor before you start. Common sense is your best guide when you answer these
questions. Please read the questions carefully and answer each one honestly: Check YES or NO.
YES
NO
1 Has your doctor ever said that you have a heart condition and that you should only
do physical activity recommended by doctor?
2 Do you feel pain in your chest doing physical activity?
3 In the past month have you had chest pain when you were not doing physical
activity?
4 Do you loose your balance because of dizziness or do you ever loose
consciousness?
5 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?
6 Is your doctor currently prescribing drugs (e.g. water pills) for your blood pressure
or heart condition?
7 Do you know of any other reason why you should not do physical activity?
IF YOU
ANSWERED
YES
IF YOU
ANSWERED
NO
ADVICE
Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or
before you have your initial screening as part of this programme. Tell your doctor about the PAR-Q and which
questions you answered YES. You may be able to do participate in any of the activities offered by starting slowly
and building gradually. Or you may need to restrict your activities to those which are safe for you. Talk with your
doctor and follow his/her advice.
You can start becoming more physically active. Begin slowly and build up gradually. This is the safest and most
beneficial way to begin a more active lifestyle. You will take part in an initial health screen at the start of the
programme which is an excellent opportunity to determine your basic fitness so that you can plan the best way
for you to live actively.
Delay becoming much more active:
If you are not feeling well because of a temporary illness such as a cold or fever; wait until you feel better.
I have read, understood and completed this questionnaire. Questions I had were answered to my full satisfaction.
Signature
Date
Print Name
Witness
Date
University College Dublin assumes no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire,
consult your doctor prior to physical activity.
Note: During participation in the UCD Better Bones Level 1 Exercise Programme, if your health changes so that you answer YES to any of the
above questions please inform your instructor.
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