PAR Q Form

  • Physical Activity Readiness Questionnaire (PAR-Q)

  • Date
     / /
  • Format: (000) 000-0000.
  • 1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*
  • 2. Do you ever feel pain in your chest when you are not performing any physical activity?*
  • 3. In the past month have you had chest pain when you were not performing any physical activity?*
  • 4. Do you have a joint or bone problem that could be made worse by a change in your physical activity?*
  • 5. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?*
  • 6. Do you lose your balance because of dizziness or do you ever lose consciousness?*
  • 7. Do you know of any other reason why you should not engage in physical activity? If yes, please explain.*

  • 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

  • MEDICAL HISTORY

  • 1. Have you ever had any recurring pain or injuries? (ankles, knees, hips, back, shoulder etc?)*
  • 2. Have you had any surgeries?*
  • 3. Has a medical doctor ever diagnosed you with chronic disease, such as coronary heart disease, coronary artery disease, hypertension, high cholesterol or diabetes?*
  • 4. Are you currently taking any medications?*

  • OCCUPATION

  • 2. Does your occupation require extended periods of sitting?
  • 3. Does your occupation require extended periods of repetitive movement?
  • 4. Which option below explains your level of stress?*

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

  • 1. How would you rate your current fitness level?
  • 2. How would you rate your cardiovascular strength?
  • 3. How would you rate your muscular strength?
  • 4. How would you rate your flexibility?

  • FITNESS GOALS

  • 1. Check all of the following that are goals you wish to accomplish.
  •  
  • Should be Empty: