ParQ
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
When was your last Physical Exam?
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Are you currently under a Doctor’s care?
Please Select
Yes
No
Are you currently taking any Medications?
Please Select
Yes
No
If yes, please list:
Have you been Hospitalized in the last YEAR?
Please Select
Yes
No
Do you have... Select ALL that apply
High blood pressure
High cholesterol
Diabetes
Rheumatic heart disease
Heart murmur
Chest pain with exertion
Irregular heartbeat or palpitations
Lightheadedness or Fainting
Asthma
Unusual shortness of breath
Cramping pain in legs or feet
Emphysema
Other metabolic disorders
Epilepsy
Back pain
Joint pain
Muscle pain
Are you Pregnant?
Tobacco Products
Please Select
Never
Quit
Smoke
Chew
Alcohol
Please Select
Never
Quit
1 per day
2 per day
3 per day
More than 3 per day
Stress Levels
Please Select
Low
Medium
High
Activity
Please Select
Low
Medium
High
Weekly Exercise Habits
Please Select
None
Once per week
Three Times per week
More than three times per week
Has anyone in your Immediate family ( Parents orSiblings ) prior to age 55 had any of the following
Heart attack
Stroke
High blood pressure
known heart disease
High cholesterol
To the best of my knowledge, the above information is true
Yes
Signature
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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