On Line Swim Class Questionnaire

No Limits On Line Swim Class Questionnaire

Question Title

* 1. Please complete the following

Name

Phone #

Age

Question Title

* 2. What event are you training for?

Sprint Distance

Olympic Distance

Half Ironman

Ironman

Please list your key race name and date

Question Title

* 3. What is your current swim fitness

Swim - Can swim for 60 min

Swim - Can swim for 30 min

Swim - Can swim for 15 min

Other (please specify)

Question Title

* 4. What type of swimmer are you?

Swimmer - Experienced strong swimmer

Swimmer - Swam as a kid but not for many years

Swimmer - Just learning

Swim Time: 1500 timed swim 30 min or more

Swim Time: 1500 timed swim 25 - 30 min

Swim Time: 1500 timed swim 23 - 25 min

Swim Time: 1500 timed swim less than 23 min

Swim time: 1500 times swim is less than 20 min

Swim Time: no idea what my 1500 time is

Other (please comment about your fitness level)

Question Title

* 5. What days do you want to swim on (pick up to three)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Other (please specify)

Question Title

* 6. Do you have any current injures or physical limitations that we should be aware of?

Yes

If Yes please list

Question Title

* 7. Are you currently swimming with a group during the week?

Yes

If Yes please list group name and training days

Question Title

* 8. Par - Q (please complete the following questions)

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? Yes or No?	Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? Yes or No? Yes	Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? Yes or No? No
Do you feel pain in your chest when you do physical activity? Yes or No	Do you feel pain in your chest when you do physical activity? Yes or No Yes	Do you feel pain in your chest when you do physical activity? Yes or No No
In the past month, have you had chest pain when you were not doing physical activity? Yes or No	In the past month, have you had chest pain when you were not doing physical activity? Yes or No Yes	In the past month, have you had chest pain when you were not doing physical activity? Yes or No No
Do you lose your balance because of dizziness or do you ever lose consciousness? Yes or No	Do you lose your balance because of dizziness or do you ever lose consciousness? Yes or No Yes	Do you lose your balance because of dizziness or do you ever lose consciousness? Yes or No No
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? Yes or No	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? Yes or No Yes	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? Yes or No No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? Yes or No	Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? Yes or No Yes	Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? Yes or No No
Do you know of any other reason why you should not do physical activity? Yes or No	Do you know of any other reason why you should not do physical activity? Yes or No Yes	Do you know of any other reason why you should not do physical activity? Yes or No No
Is the information you have entered in this questionnaire accurate and true? (NOTE YOU SHOULD ANSWER YES HERE)	Is the information you have entered in this questionnaire accurate and true? (NOTE YOU SHOULD ANSWER YES HERE) Yes	Is the information you have entered in this questionnaire accurate and true? (NOTE YOU SHOULD ANSWER YES HERE) No

If you answered Yes to one or more questions. Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.