Fort Phoenix - Health Questionnaire

Physical Activity Readiness Questionnaire (PAR-Q)

Regular physical activity is fun and healthy, and more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the eight questions in the box below. If you are between the ages of 15 and 69, the PARQ will tell you if you should check with your doctor before you start. If you are over 69 years of age and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO.

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* 1. Please fill in your contact information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. What's your date of birth?

Date

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

Yes

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* 4. Do you feel pain in your chest when you do physical activity?

Yes

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* 5. In the past month, have you had chest pain when you were not doing physical activity?

Yes

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

Yes

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* 7. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?

Yes

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* 8. Is your doctor currently prescribing drugs for your blood pressure or heart condition?

Yes

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* 9. Are you or have you been pregnant in the last 6 months?

Yes

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* 10. Do you know of any other reason why you should not do physical activity?

Yes

If Yes, please give more details