ParQ

ParQ

Physical Activity Readiness Questionnaire
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a physician?*
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing you with medication for your blood pressure or for a heart condition?
Do you know of any other reason you should not engage in physical activity?
Signature

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If you Answered 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 medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
What is your current occupation?
Does your occupation require extended periods of sitting?
Does your occupation require you to wear shoes with a heel? (dress shoes)
Does your occupation cause you mental stress?
Does your occupation require repetitive movements? If yes please explain.
Do you partake in recreational activities? (golf, skiing,etc.) If yes please explain.
Do you have any additional hobbies? (Reading, video games etc.) If yes please explain.
Have you ever had any injuries or chronic pain? If yes please explain.
Have you ever had any surgeries? If yes please explain.
Has a medical doctor ever diagnosed you with chronic diseases such as heart disease, hypertension, high cholesterol, or diabetes? If yes please explain.
Do you Smoke?
Are you currently taking many medication? If yes please explain.
Signature

Clear
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ParQ

If you Answered 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 medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.