ParQ_Screening

Par Q

Physical Activity Readiness Questionnaire
Full Name

First NameLast Name
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Sex
Phone Number
Email Address
Occupation
Heart Condition?
Chest Pains?
Low / High Blood Pressure?
Dizziness During / After Physical Exercise?
Pre / Post Natal?
Medication?
Joint Bone Issues?
Currently Injured?
Currently Ill?
Mental Health Issues?
Do you know any reason you should not exercise or do physical activity?
If you answered yes to any of the above questions, talk with your Doctor BEFORE you begin training. Tell the doctor of your intention to exercise and which questions you answered ‘yes’ to. If at any stage your health changes , resulting in a ‘yes’ answer to the above questions please seek guidance from a GP.
Problem Areas
Goals
Exercise History
Dietary Issues
Smoker
Alcohol Intake
Hours Sleep Per Day
Weight (kg)
Height (cm)
Activity Level
Do you give ENGAGE101 FITNESS permission to be able to use your image for promotional & advertisement purposes?
Date
Signature
Should be Empty:

Par Q