Physical Questionnaire

PROGRAMA TRANSFORMACION

cuestionario de evaluacion

Nombre*

First NameLast Name

Phone

Area CodePhone Number

E-mail*

Edad*

Estatura*

Peso*

Physical activity should not be hazardous for most people. The PAR-Q has been designed to identify those adults who should consult a physician prior to beginning a program of physical exercise.

1. Cuando fue el ultimo examen medico?

2. Actualmente tomas medicamentos?

Si, cuales?

3. Fumas?

4. Tienes colesterol elevado?

5. Eres diabetico?

6. Padeces hipertension?

10. Has your doctor ever told you that you have a bone or joint problem (such as arthrtis) that has been aggravated by activity?

11. Have you ever had any surgery, broken bones or sprains?

If yes, what kind and how long ago?

12. Are you pregnant, if yes what trimester and due date?

13. Is there any reason not mentioned thus far that would not allow you to participate in a physical fitness program?

If you answered yes to any of the previous questions, please answer the following:

14. have you consulted your physician regarding an increase in your physical activity?

15. If you answered NO to question 11, will you consult your physician regarding an increase in your pysical activity?

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