Modified Physical Activity Readiness Questionnaire (PAR-Q)

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Name: 

Phone:

 

Address:

Date of Birth:

Email Address:

Name of Person Who Referred You?

 

Yes

No

Has a physician ever said you have a heart condition and you should only do physical activity recommended by a physician?

Yes

No

 When you were not doing physical activity, have you had chest pain in the past month?

Yes

No

Do you ever lose consciousness or do you lose your balance because of dizziness?

Yes

No

 Do you have a joint or bone problem that may be made worse by a change in your physical activity?

Yes

No

 Is a physician currently prescribing medications for your blood pressure or heart condition?

Yes

No

 Are you pregnant?

Yes

No

Do you have insulin dependent diabetes?

Yes

No

Do you know of any other reason you should not exercise or increase your physical activity?

Yes

No

Are you experiencing any physical pain that we should discuss prior to your workout?