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.