Par-Q Questionnaire

Please fill in the form below.

What is a Par Q questionnaire?

If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity pattern. If you are over 69 years of age and are not used to being very active, check with your doctor before you partake in any exercise.

PLEASE FILL IN THE BELOW:

Full name:(required)

Date of birth:(required)

Emergency contact name:(required)

Emergency contact number:(required)

Surgery name:(required)

Doctor's name:(required)

Please read carefully and answer each question honestly, answering yes or no where appropriate.

1. Has your doctor told you that you have a heart condition and that you should only perform physical activity recommended by a doctor?(required)

2. Do you feel pain in your chest when performing physical activity?(required)

3. Have you experienced chest pain when NOT performing physical activity in the last month?(required)

4. Do you lose your balance because of dizziness or have you lost consciousness recently?(required)

5. Do you have any bone or joint problems such as arthritis which could be aggravated through physical activity?(required)

6. Is your doctor currently prescribing you medications for high blood pressure or a heart condition?(required)

7. Have you had an operation in the last 12 months?(required)

8. Is there any reason why you should NOT participate in physical activity?(required)

If you answered YES to the final question, please give your reason(s) below:

If you answered Yes: If you answered yes to one or more questions, are older than age 40 and have been inactive or are concerned about your health please consult a physician before substantially increasing your physical activity. You should ask for medical clearance along with information about specific exercise limitations you may have. In most cases you will still be able to take part in physical activity as long as you adhere to guidelines.

If you answered No: If you answered no to all the questions above you can be reasonably sure that you can exercise safely and have a low risk of having any medical complications from exercise. It is still important to start exercising slowly and increase intensity gradually. It may also be helpful to have a fitness assessment with a fitness instructor or personal trainer in order to determine where to begin.

*Please note*: If your health changes so that subsequently you answer YES to any of the above questions, please inform your fitness or health professional immediately and ask whether you should change your physical activity or exercise plan.

If you answered NO to all of the above, please fill in the below:

Declaration

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise and my participation may involve a risk of injury.

Your full name:(required)

Today's date:(required)

Trainer’s name: Kelly Hayes

*Please note*: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes, which may mean that you would answer YES to any of the questions above. If your condition does change, please inform your trainer.

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