Active Stars Pre-Workshop Questionnaire

Your details

All fields required

Parent/Carer's Name (required)

Child's Name (required)

Child's Age (required)

Child's Date of Birth (required)

Child's Gender (required)MaleFemale

Address (required)

Postcode (required)

Contact Number (required)

Email Address (required)

What is your child's ethnic group?
White
BritishAny other White background

Mixed
White and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed background

Black or Black British
CaribbeanAfricanAny other Black background

Asian or British Asian
IndianPakistaniBangladeshiAny other Asian background

Other Ethnic Groups
ChineseAny Other background

Emergency Contact

Full Name (required)

Contact Number (required)

How did you find out about the activity?

Are you new to sport? (i.e. not involved in physical activity for the past year)YesNo

How many minutes of activity have you done in the last week?0 mins0-30 mins30-60 mins60-90 mins90-150 mins150+ mins

Are you happy for us to contact you regarding cancellations, changes or additions to the programme?YesNo

____________________

Pre-Activity Readiness Questionnaire (PAR-Q)

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?YesNo
Do you feel pain in your chest when you do physical activity?YesNo
In the past month, have you had chest pain when you were not doing physical activity?YesNo
Do you lose your balance because of dizziness or do you ever lose consciousness?YesNo
Do you have a bone or joint problem that could be made worse by a change in your physical activity?YesNo
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?YesNo
Do you know of any other reason why you should not do physical activity?YesNo

If you answered YES:
If you answered yes to one or more questions, are older than age 40 and have been inactive or are concerned about your health, consult a physician before taking a fitness test or substantially increasing your physical activity. You should ask for a medical clearance along with information about specific exercise limitations you may have. In most cases, you will still be able to do any type of activity you want as long as you adhere to some guidelines.

If you answered NO:
If you answered no to all the PAR-Q questions, you can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowing and increase gradually. It may also be helpful to have a fitness assessment with a personal trainer or coach in order to determine where to begin.

When to delay the start of an exercise program:
• If you are not feeling well because of a temporary illness, such as a cold or a fever, wait until you feel better to begin exercising.
• If you are or may be pregnant, talk with your doctor before you start becoming more active.

About your child

How often has your child had each of the following food/drink items in the past 24 hours:

Fruit and vegetables
1 portion (including fresh, frozen and tinned) =½ apple, 1 plum, ½ medium carrot, ½ to 1 heaped tablespoon beans, e.g. chick peas012345+

Soft drinks / squashes / other sweetened drinks
(including fruit juice based drinks like Rubicon, Ribera, Fruit Shoots)012345+

Unsweetened juice
(e.g. 100% juice, including juice that you dilute down with water in your child’s cup)012345+

Water012345+

Pre-sugared cereals (e.g. coco pops, fruit loops) or sugar added to cereal012345+

Potato chips/crisps, sweet biscuits, chocolate (bar, block or coated biscuit), other sweet snacks (e.g. cakes, ice cream)012345+

My child takes part in structured physical activities e.g. sports lessons, clubs, swimming..daily2-3 times weeklyonce a weekevery two weeksonce a monthless than once a monthnever

My child is active through outdoor play and recreational activities at home..daily2-3 times weeklyonce a weekevery two weeksonce a monthless than once a monthnever

On a typical day, my child is active (through walking to school, cycling, active play, sports lessons etc) for approximately...
(hours and minutes)

On a typical day, my child plays computer games and/or watches television (including watching films etc) for..30 minutes1 hour2 hours4 hours6 hours

Child Questionnaire - this section MUST be filled in by your CHILD ONLY

Please indicate how strongly you agree or disagree with each statement.

On the whole, I am satisfied with myself.Strongly AgreeAgreeDisagreeStrongly Disagree

At times, I think I am no good at all.Strongly AgreeAgreeDisagreeStrongly Disagree

I feel that I have a number of good qualities.Strongly AgreeAgreeDisagreeStrongly Disagree

I am able to do things as well as most other people.Strongly AgreeAgreeDisagreeStrongly Disagree

I feel I do not have much to be proud of. Strongly AgreeAgreeDisagreeStrongly Disagree

I certainly feel useless at times.Strongly AgreeAgreeDisagreeStrongly Disagree

I feel that I'm a person of worth, at least on an equal plane with others.Strongly AgreeAgreeDisagreeStrongly Disagree

I wish I could have more respect for myself.Strongly AgreeAgreeDisagreeStrongly Disagree

All in all, I am inclined to feel that I am a failure.Strongly AgreeAgreeDisagreeStrongly Disagree

I take a positive attitude toward myself. Strongly AgreeAgreeDisagreeStrongly Disagree

-END of Child Questionnaire-

Child's Measurements

Child's Height (required)

Child's Weight (required)

Child's Waist Circumference (required)

We will contact you in 3-6months time to see whether you need any further support on healthy eating and to ask you a few questions about healthy eating. If you do not want us to do this please tick this box.

Terms and Conditions
Please agree to our terms and conditions by ticking the box:
I confirm that I understand that participation in this group or class is entirely at my own risk and I should consult my doctor if suffering from any condition that might make taking part injurious to my health.

Signature (required) - please enter your full name

Date

Please make sure you have agreed to our terms and conditions before submitting.