• Participant Declaration for ParQ

  • Format: (000) 000-0000.
  • Has your doctor ever said that you have a heart condition?*
  • Has your doctor ever said you have 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)?*
  • Are you currently taking prescribed medications for a chronic medical condition?*
  • 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.*
  • Has your doctor ever said that you should only do medically supervised physical activity?*

  • PARTICIPANT DECLARATION

    If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.            

    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 its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

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