Physical Activity Readiness Questionnaire (PARQ)

Full Name*

First NameLast Name

The PAR-Q has been designed to highlight health concerns that individuals should speak to their doctor about and to reduce the risk of injury related to exercise.

Please read the following questions carefully and check (X) next to the appropriate answers.

YES/ NO*

	Yes	No
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Are you pregnant now or have given birth within the last 6 months?
Have you had a recent surgery?
Are you currently on any medications, either prescription or non-prescription, on a regular basis?

If you have any current /ongoing injuries, please list them

If you have answered 'Yes' to any of the above, please elaborate below:

Fitness Participation Agreement

I have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent me from participation. I acknowledge that participation is at my own pace and comfort level and that I may discontinue my participation in the sessions at any time. Furthermore, I agree to self-determine my exertion through good judgement and to discontinue any activity that exceeds my personal limitations. I affirm that I have read and understand this document and I wish to participate in fitness activities.

Date

Signature of Participant:*