• PAR-Q

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  • Format: (000) 000-0000.

  • GENERAL HEALTH QUESTIONS

    Please read the 7 questions below carefully and answer each one honestly: check YES or NO.
  • Has your doctor ever said that you have a heart condition OR high blood pressure?
  • Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?
  • Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).
  • Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? PLEASE LIST CONDITION(S) BELOW:
  • Are you currently taking prescribed medications for a chronic medical condition? PLEASE LIST CONDITION(S) AND MEDICATIONS BELOW:
  • Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. PLEASE LIST CONDITION(S) BELOW:
  • Has your doctor ever said that you should only do medically supervised physical activity?

  • FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S)

  • Do you have Arthritis, Osteoporosis, or Back Problems?
  • Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
  • Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?
  • Have you had steroid injections or taken steroid tablets regularly for more than 3 months?
  • Do you currently have Cancer of any kind?
  • Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?
  • Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?
  • Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm
  • Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
  • Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction)
  • Do you have chronic heart failure?
  • Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?
  • Do you currently have High Blood Pressure?
  • Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
  • Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)
  • Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes
  • Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?
  • Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.
  • Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?
  • Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?
  • Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?
  • Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer's, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome
  • Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
  • Do you have Down Syndrome AND back problems affecting nerves or muscles?
  • Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure
  • Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
  • Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?
  • If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?
  • Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?
  • Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia
  • Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
  • Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?
  • Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?
  • Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event
  • Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
  • Do you have any impairment in walking or mobility?
  • Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?
  • Do you have any other medical condition not listed above or do you have two or more medical conditions?
  • Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?
  • Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?
  • Do you currently live with two or more medical conditions?

  • 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 the community/fitness center may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

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  • Format: (000) 000-0000.
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