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PAR-Q

(Physical Activity Readiness Questionnaire)

Please fill out the following form prior to your initial assessment.


(If you answer YES to one or more of the below 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.

Name*

DOB*

Height*

Weight*

Primary Care Provider and Contact Number*

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*

Select an option

Do you feel pain in your chest when you perform physical activity?*

Select an option

In the past month, have you had chest pain when you were not performing any physical activity?*

Select an option

Do you lose your balance because of dizziness or do you ever lose consciousness?*

Select an option

Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

Select an option

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?*

Select an option

Do you know of any other reason why you should not engage in physical activity?*

Select an option

What is your current occupation?*

Does your occupation require extended periods of sitting?*

Select an option

Does your occupation require repetitive movements? If so, please explain.*

Select an option

Does your occupation require you to wear shoes with a heel(dress shoes)?*

Select an option

Does your occupation cause you mental stress?*

Select an option
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