Physical Activity Readiness Questionnaire (PAR-Q)

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 patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Common sense is your best guide when answering these questions. Please read carefully and answer each one honestly: check YES or NO.

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

Yes

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

Yes

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

Yes

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* 4. Do you lose balance or dizziness or do you ever lose consciousness?

Yes

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* 5. 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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* 6. Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes

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

Yes

Other (please specify)

YES to one or more questions:
You should consult with your doctor to clarify that it is safe for you to become physically active at the current time and in your current state of health.

NO to all questions:
It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.

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* 8. Through printing your name and entering the date below, you are confirming that you are voluntarily engaging in an
acceptable level of exercise, and your participation involves a risk of injury.

Print Name (Sign):

Date:

Email Address:

Contact Number:

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* 9. Having answered YES to one of the above, you are printing your name and adding the date to confirm you have sought medical advice and your GP has agreed that you may exercise.

Print Name (Sign):

Date:

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 so that you would answer YES to any of the 7 questions.

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

Question Title

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

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

Question Title

* 4. Do you lose balance or dizziness or do you ever lose consciousness?

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* 5. 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?

Question Title

* 6. Is your doctor currently prescribing medication for your blood pressure or heart condition?

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

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* 8. Through printing your name and entering the date below, you are confirming that you are voluntarily engaging in an acceptable level of exercise, and your participation involves a risk of injury.

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* 9. Having answered YES to one of the above, you are printing your name and adding the date to confirm you have sought medical advice and your GP has agreed that you may exercise.

* 8. Through printing your name and entering the date below, you are confirming that you are voluntarily engaging in an
acceptable level of exercise, and your participation involves a risk of injury.