Client Information, PAR-Q & GMQ

Client Information, PAR-Q & GMQ

Physical Activity Readiness & General and Medical Questionnaires
Client Information
Legal Name

First and Middle NameLast Name
Preferred Name
Preferred Pronouns
Email
example@example.com
Phone Number
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Date of Birth

MonthDayYear
DOB MM-DD-YYYY
Current Age
Primary physical address where you will participate in sessions
Primary Local Emergency Response Phone Number
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Primary Time Zone
Secondary physical address (second home or other place you might do sessions from)
Secondary Local Emergency Response Phone Number
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Secondary Time Zone
Local Emergency Response Phone Number
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Emergency Contact Name & Relation
Name and Relation
Emergency Contact Phone Number
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PAR-Q

Physical Activity Readiness Questionnaire
1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
2. Do you feel pain in your chest when you perform physical activity?
3. In the past month, have you had chest pain when you were not performing any physical activity?
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
6. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
7. Do you know of ANY other reason why you should not engage in physical activity?
If you answer “Yes” to one or more of the above questions, consult your physician BEFORE engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

If you answered "NO" honestly to all PAR-Q questions, you can be reasonably sure that you can:
- Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.
- Take part in a fitness appraisal – this is an excellent way to determine your
  basic fitness so that you can plan the best way for you to live actively.
Delay becoming much more active:
- If you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better.
- If you are or may be pregnant – talk to your doctor before you start becoming more active.
*Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.
GMQ

General and Medical Questionnaire
Occupational Questions
1. What is your current occupation?
2. Does your occupation require periods of repetitive motion? If "yes," please explain.
3. Does your occupation require extended periods of sitting? If "Yes," please explain.
4. Does your occupation require you to wear dress shoes?
5. Does your occupation cause you anxiety or mental stress?
Recreational Questions
6. Do you partake in any recreational activities or sports such as: golf, tennis, skiing, running, cycling etc. If "yes," please list the activity and frequency which you engage with the activity ie "running twice a week" or "tennis on Saturdays."
7. Do you have any hobbies such as: reading, gardening, knitting, working on cars, etc? If "yes," please list your hobbies and frequency which you enjoy them. i.g. "knitting daily" or "gardening on weekends."
8. Do you partake in alcohol, tobacco or other recreational drugs? If "Yes," please list what and how often, i.g. "wine with dinner" or "CBD/THC when stressed."
Medical Questions
9. Have you ever had any pain or injuries to your joints or bones (ankle, knee, hip, back, neck, shoulder etc.)? If “Yes” please describe the injury and how long ago.
10. Have you had any surgeries? If “Yes” please explain. Please include wisdom teeth extractions, tonsillectomies, appendectomies, eye surgeries etc. Please include the year of OR your age of the surgery.
11. Has a medical doctor ever diagnosed you with a chronic disease such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? If “Yes” please explain.
12. Are you currently taking any medication? If “Yes” please explain. Please list all prescription medications and what is is prescribed for
13. Do you wear corrective vision (glasses or contracts) or have you had Lasik or other eye surgery to correct your vision? If "Yes," Please include your eye prescription or year of surgical correction.
14. Do you have any allergies? If "Yes," please list them.
15. Do you have asthma or any other respiratory issues?
16. Do you have diabetes?
17. Do you have anything else you would like to mention?
Participant Declaration
All persons who have completed the PAR-Q and GMQ please read and sign the declaration below.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that Leela Ha (Leela Ha Wellness) may retain a copy of this form for records. In these instances, Leela Ha (Leela Ha Wellness) will maintain the confidentiality of the same, complying with applicable law.
Full Name

First and Middle NameLast Name
Signature
Date

MonthDayYear
Date
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Client Information, PAR-Q & GMQ

Client Information

PAR-Q

GMQ

Occupational Questions

Recreational Questions

Medical Questions

Participant Declaration