Form

PAR Q

(Physical Activity Readiness Questionnaire)
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What are your main reasons for starting?
Has your doctor ever said you have a heart condition and 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 have you had a chest pain when you were not doing physical activity?
Do you loose balance because of dizziness or do you ever loose consciousness?
Do you have a bone or joint problem (eg back/hip/knee) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you know any other reason why you should not take part in physical activity?
If YES, please comment below:
IF YOU ANSWERED YES TO ONE OR MORE QUESTIONS:

You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.
I HAVE READ, UNDERSTOOD AND ACCURATELY COMPLETED THIS QUESTIONNAIRE.
I CONFIRM THAT I AM VOLUNTARILY ENGAGING IN AN ACCEPTABLE LEVEL OF EXERCISE, AND MY PARTICIPATION INVOLVES A RISK OF INJURY.
HAVING ANSWERED YES TO ONE OR MORE OF THE QUESTIONS ABOVE, I HAVE SOUGHT MEDICAL ADVICE AND MY GP HAS AGREED THAT I MAY EXERCISE
Signature
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

PAR Q