PAR Q Form

Physical Activity Readiness Questionnaire (PAR-Q)
Name*
Date

MonthDayYear
Phone Number*
Physician's Name
Physician's Number
1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*

YesNo
2. Do you ever feel pain in your chest when you are not performing any physical activity?*

YesNo
3. In the past month have you had chest pain when you were not performing any physical activity?*

YesNo
4. Do you have a joint or bone problem that could be made worse by a change in your physical activity?*

YesNo
5. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?*

YesNo
6. Do you lose your balance because of dizziness or do you ever lose consciousness?*

YesNo
7. Do you know of any other reason why you should not engage in physical activity? If yes, please explain.*

YesNo
If you have answered "Yes" to one or more of the above questions, please consult your physician before engaging in any physical activity. Tell your physician which questions you answered "Yes" to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
EXERCISE HISTORY
Are you currently exercising on a regular basis? If yes, how long, how often, and what activities does your routine consist of?*
2. Do you partake in any recreational activities? (Golf, tennis, skiing, etc.?) If yes, please explain.*
3. Do you have any hobbies? (reading, gardening, sewing, working on cars, exploring the internet? etc.) If so, please elaborate.*
MEDICAL HISTORY
1. Have you ever had any recurring pain or injuries? (ankles, knees, hips, back, shoulder etc?)*

YesNo
If yes, please explain.
2. Have you had any surgeries?*

YesNo
If yes, please explain.
3. Has a medical doctor ever diagnosed you with chronic disease, such as coronary heart disease, coronary artery disease, hypertension, high cholesterol or diabetes?*

YesNo
If yes, please explain.
4. Are you currently taking any medications?*

YesNo
If yes, please list them.
OCCUPATION
1. What is your current occupation?
2. Does your occupation require extended periods of sitting?

YesNo
3. Does your occupation require extended periods of repetitive movement?

YesNo
If yes, please explain.
4. Which option below explains your level of stress?*

Very HighAbove AverageAverageBelow AverageNone
NUTRITION + PHYSICAL CONDITION SELF-EVALUATION (1 being the lowest, 5 being the highest)
1. How would you rate your current fitness level?

12345
2. How would you rate your cardiovascular strength?

12345
3. How would you rate your muscular strength?

12345
4. How would you rate your flexibility?

12345
5. On a scale from 1-10, how would you rate your motivation level?
FITNESS GOALS
1. Check all of the following that are goals you wish to accomplish.

Lose WeightDecrease Body FatTone + Firm BodyIncrease StrengthIncrease Muscle MassGain Weight
2. What is your primary fitness goal?
Should be Empty:

Physical Activity Readiness Questionnaire (PAR-Q)

EXERCISE HISTORY

MEDICAL HISTORY

OCCUPATION

NUTRITION + PHYSICAL CONDITION SELF-EVALUATION (1 being the lowest, 5 being the highest)

FITNESS GOALS