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Susie Bergman
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About
Contact
PAR-Q
Physical Activity Readiness Questionnaire (PAR-Q)
Name
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First Name
Last Name
Email
*
Date
*
MM
DD
YYYY
Height
Weight
Age
Physician's Name
*
Phone Number
*
(###)
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Emergency Contact
*
Phone Number
*
(###)
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PHYSICAL ACTIVITY READINESS QUESTIONNAIRE
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
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Yes
No
Do you feel pain in your chest when you perform physical activity?
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Yes
No
In the past month, have you had chest pain when you were not performing any physical activity?
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Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
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Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
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Yes
No
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
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Yes
No
Do you know of any other reason why you should not engage in physical activity?
*
Yes
No
Occupational Questions
What is your current occupation?
Does your occupation require extended periods of sitting? If yes, how many hours?
Does your occupation require extended periods of repetitive movements? If yes, please explain.
Does your occupation cause you anxiety or mental stress?
Recreational Questions
Do you participate in any recreational activities (golf, tennis, skiing, etc.)? If yes, please explain.
Do you have any hobbies (reading, gardening, working on cars, playing video games, etc.)? If yes, please explain.
Medical Questions
Please explain any pain, injuries, tightness or imbalances you have or have experienced in the past (ankle, knee, hip, back, shoulder, neck, etc.)
Have you ever had any surgeries? If yes, please explain.
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? If yes, please explain.
Are you currently taking any medication? If yes, please list.
To the best of my knowledge, the above information is true.
Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
Thank you!