Physical Activity Readiness Questionnaire
All information received will be treated as strictly confidential. Please write a narrative completely and accurately. This information is essential to help develop a program that addresses your needs, goals and is safe and effective. The PAR-Q is designed to identify clients for whom physical activity might not be appropriate or to determine medical caution for exercise.
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Please write a detailed narrative below to any of the following questions that are a "YES" answer.
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1. Do you have shortness of breath upon exertion?
2. Do you have leg cramps?
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3. Do you have ankle swelling?
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4. f you have bone or join problem, please explain.
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5. Do you lose balance due to dizziness or faint?
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6. Have you been diagnosed with high blood pressure (>140/90)?
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7. Do you have High cholesterol levels (greater than 200)?
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8. Do you have chronic illness or condition?
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9. Are you taking a beta-blocker?
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Do you have a heart condition or heart palpitations??
10. Do you have a muscle, joint, or back disorder (past injuries as well)
11. Do you smoke?
12. Have you been diagnosed with diabetes?
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13. Are you pregnant?
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14. Do you have Peripheral vascular disease (i.e. ankle swelling)
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15. Do you have Osteoporosis?
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16. Do you have diabetes or any other medical conditions?
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17. Are you under a doctor’s care?
18. List any/all medical conditions you are taking below.
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19. List any past operations or hospitalizations
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20. Do you know of any other reason why you should not participate in physical activity? If "YES", please include a detailed written narrative below.
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I hereby understand the risks and have answered the information provided above to the best of my knowledge and ability.