YL Fit & Wellness LLC – Physical Activity Readiness Questionnaire (PAR-Q)
Please complete this form to help us assess your readiness for physical activity and ensure your safety.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Health Assessment Questions
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
*
Yes
No
2. Do you feel pain in your chest when you do physical activity?
*
Yes
No
3. In the past month, have you had chest pain when not physically active?
*
Yes
No
4. Do you lose your balance because of dizziness or have you ever lost consciousness?
*
Yes
No
5. Do you have a bone, joint, or musculoskeletal problem that could be made worse by a change in physical activity?
*
Yes
No
6. Is your doctor currently prescribing medications for your blood pressure or heart condition?
*
Yes
No
7. Do you know of any other reason why you should not participate in physical activity or exercise?
*
Yes
No
Accessibility & Communication Preferences
Accessibility accommodations for communication
*
American Sign Language (ASL) Interpretation
Captioned Telehealth Sessions
Written Communication
No Accommodation Needed
Other
If other, please specify
Electronic Signature
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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