Regular physical activity is fun and healthy, and increasingly 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 more physically active. Please complete this form as accurately and completely as possible.
PAR-Q FORM Please mark YES or No to the following: YES NO
Has your doctor ever said that you have a heart condition and recommended
only medically supervised physical activity? ____ ____
Do you frequently have pains in your chest when you perform physical activity? ____ ____
Have you had chest pain when you were not doing physical activity? ____ ____
Have you had a stroke? ____ ____
Do you lose your balance due to dizziness or do you ever lose consciousness? ____ ____
Do you have a bone, joint or any other health problem that causes you pain or
limitations that must be addressed when developing an exercise program
(i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis,
anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? ____ ____
Are you pregnant now or have given birth within the last 6 months? ____ ____
Do you have asthma or exercise induced asthma? ____ ____
Do you have low blood sugar levels (hypoglycemia)? ____ ____
Do you have diabetes? ____ ____
Have you had a recent surgery? ____ ____
If you have marked YES to any of the above, please elaborate below:
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Do you take any medications, either prescription or non-prescription, on a regular basis? Yes/No
What is the medication for?
How does this medication affect your ability to exercise or achieve your fitness goals?
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Please note: If your health changes such that you could then answer YES to any of the above
questions, tell your trainer/coach. Ask whether you should change your physical activity plan.
I have read, understood, and completed the questionnaire. Any questions I had were answered to my full satisfaction.
Print Name: _________________________________Signature:____________________________
Date: _______________________________________
