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.

Please write a detailed narrative below to any of the following questions that are a "YES" answer.

1. Do you have shortness of breath upon exertion?


2. Do you have leg cramps?

3. Do you have ankle swelling?

4. f you have bone or join problem, please explain.

5. Do you lose balance due to dizziness or faint? 

6. Have you been diagnosed with high blood pressure (>140/90)?

7. Do you have High cholesterol levels (greater than 200)?

8. Do you have chronic illness or condition? 

9. Are you taking a beta-blocker? 

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?

13. Are you pregnant?

14. Do you have Peripheral vascular disease (i.e. ankle swelling) 

15. Do you have Osteoporosis?

16. Do you have diabetes or any other medical conditions? 

17. Are you under a doctor’s care?


18. List any/all medical conditions you are taking below.

19. List any past operations or hospitalizations

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.

I hereby understand the risks and have answered the information provided above to the best of my knowledge and ability.