(PAR-Q)

Physical Activity Readiness Questionnaire (PAR-Q)
Name*

First NameLast Name
D.O.B*

DayMonthYear
Address*
Contact Number*
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start.
1. Have you ever been advised that your blood pressure was/is high/low?*

YesNo
2. Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor?*

YesNo
3. Do you feel pain in your chest when you do physical activity?*

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

YesNo
5. Do you have any breathing difficulties, including asthma & bronchitis?*

YesNo
If yes, details
6. Do you, or have you ever smoked on a regular basis?*

YesNo
If yes, details
7. Do you have a bone/joint problem, ligament injuries, dislocations, sprains/strains, bone fractures or arthritis that could be made worse by a change in your physical activity?*

YesNo
If yes, details
(Your coach may request a clearance or guidance from your allied health professional before prescribing physical activity)
8. Do you have any blood disorders including diabetes, hypoglycemia and anemia?*

YesNo
If yes, details
9. Do you suffer from any form of epilepsy?*

YesNo
If yes, details
10. Do you have any other medical conditions that may affect your fitness program? (The more info, the better)*

YesNo
If yes, details
11. Do you take any medications or vitamins?*

YesNo
If yes, details
Emergency contact Name*

First NameLast Name
Emergency contact mobile number*
Format: (000) 000-0000.
"I have read, understood and completed this questionnaire truthfully to the best of my knowledge. Any questions I had were answered to my full satisfaction."
Full Name
Signature*
Date*

DayMonthYear
Date
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Physical Activity Readiness Questionnaire (PAR-Q)