Par-Q Physical Activity Readiness Questionnaire

1) Has your doctor ever said that you have a heart condition OR high blood pressure ?*
Yes, high blood pressure
Yes, I have a heart condition
Yes, I have both
No

2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
Yes
No

3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).*
Yes
No

4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? PLEASE LIST CONDITION(S) HERE OR TYPE NONE: *

5) Are you currently taking prescribed medications for a chronic medical condition? PLEASE LIST MEDICATIONS HERE OR TYPE NONE*

6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. PLEASE LIST CONDITION(S) HERE:*

7) Has your doctor ever said that you should only do medically supervised physical activity?*
Yes
No

(FOR ADULT CLIENTS ONLY) Please type in your height in ft. and inches. Copy

If you answered "yes" to any of the questions above please ask for the continuation of this questionnaire. If you answered No or None to all questions you are cleared for physical activity. Thank you!

Par-Q Physical Activity Readiness Questionnaire

Who will be participating?

Signee Information

If you answered "yes" to any of the questions above please ask for the continuation of this questionnaire. If you answered No or None to all questions you are cleared for physical activity. Thank you!

Please enter participants' full names: