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PAR-Q Questionaire
Please complete the PAR-Q Questionaire
First Name
Today's Date
Height
Health Care Provider
Last Name
Date of Birth
Weight
Phone
Questions:
1. Has your health care provider 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 performing physical activity?
3. Have you experienced chest pain when NOT performing physical activity in the last month?
4. Do you loose balance because of dizziness or have you lost consciousness recently?
5. Do you have any bone or joint problems (back, knee, hip, etc.) such as arthritus, which could be aggravated through physical activity?
6. Is your doctor currently prescribing you medication for high blood pressure or a heart condition?
7. Is there any reason why you should not participate in physical activity? If yes, please describe below
Do you currently exercise on a regular basis (3+ times per week)?
If 'YES' to any questions:
If 'NO' to all questions:
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Signature Guardian
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Thank you! We’ll be in touch.
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