Physical Activity Readiness Questionnaire (PAR-Q) Form

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

Yes/No

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

Yes/No

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

Yes/No

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

Yes/No

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

Yes/No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes/No

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

Yes/No

Please elaborate on why you selected 'Yes' to one of the questions:

Long Answer

Full Legal Name

Name

Confirmation

Consent

Client Signature

Signature