Name *
Name
D.O.B. *
D.O.B.
Phone *
Phone
Physicians Phone
Physicians Phone
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
The Physical Activity Readiness Questionnaire Being physically active is very safe for most people. Some people, however, should check with their doctors before they increase their current level of activity. The PAR-Q has been designed to identify the small number of adults for whom physical activity may be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
Do you feel pain in your chest when you do physical activity? *
In the past month, have you had chest pain when you were not doing physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *
Do you know of any other reason why you should not do physical activity? *
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.
Physical Fitness & Health History
Describe any type of exercise you currently do on a regular basis.
Describe any diets / nutrition resources, and/or routines you have practiced in the past three moths.
Do you have, or have you had in the past:
History of heart problems, chest pain, or stroke? *
Elevated blood pressure? *
Any chronic illness or condition? *
Difficulty with physical exercise? *
Advice from physician not to exercise? *
Recent surgery (last 12 months)? *
Pregnancy (now or within last 3 months) *
History of breathing or lung problems? *
Muscle, joint, or back disorder, or any previous injury still affecting you? *
Diabetes or metabolic syndrome? *
Thyroid condition? *
Cigarette smoking habit? *
Obesity [body mass index (BMI) ≥30 kg/m2]? *
Elevated blood cholesterol? *
History of heart problems in immediate family? *
Hernia, or any condition that may be aggravated by lifting weights or other physical activity? *
Please give details below (medications, orthopedic injuries, dates,...)