Date MM slash DD slash YYYY First Name(Required) Last Name(Required) Email Phone(Required)WeightHeight (approximate) AgeGeneral & Medical QuestionnairePhysical Activity Readiness Questionnaire (PAR-Q)1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?(Required) Yes No 2. Do you feel pain in your chest when you perform physical activity? Yes No 3. In the past month, have you had chest pain when you were not performing any physical activity? Yes No 4. Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No 5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No 6. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? Yes No 7. Do you know of any other reason why you should not engage in physical activity? Yes No 8. Are you pregnant? Yes No Occupational Questions1. What is your current occupation? 2. Does your occupation require extended periods of sitting? Yes No 3. Does your occupation require extended periods of repetitive movements? (If yes, please explain.) Yes No Extended periods of repetitive movements explanation(Required)4. Does your occupation require you to wear shoes with a heel (dress shoes)? Yes No 5. Does your occupation cause you anxiety (mental stress)? Yes No Recreational Questions6. Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.) Yes No Recreational activities explanation(Required)7. Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.) Yes No Hobbies explanation(Required)Medical Questions8. Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.) Yes No Pain or injuries explanation(Required)9. Have you ever had any surgeries? (If yes, please explain with dates) Yes No Surgeries explanation(Required)10. 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, diabetes, osteopenia or osteoporosis? (If yes, please explain.) Yes No Chronic disease explanation(Required)11. Are you currently taking any medication? (If yes, please list.) Yes No Medications(Required)12. Do you practice stress management? (if yes, please explain) Yes No Stress Management ExplanationIf you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.NameThis field is for validation purposes and should be left unchanged. Δ
