Physical Activity Readiness Questionnaire (PAR-Q)

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Please read each question carefully and answer each one honestly.

This questionnaire is to be used by individuals between the ages of 15 and 69. If you are over the age of 69 please check with your doctor before participating in physical activity.

This form is based on the Physical Activity Readiness Questionaire written by the Canadian Society for Exercise Physiology (www.csep.ca/forms.asp). Alternatively, you can access the official CSEP PAR-Q form at http://www.csep.ca/cmfiles/publications/parq/par-q.pdf, complete, and email to utgsu.immunology@gmail.com.

If you have any questions, please reach out to us at utgsu.immunology@gmail.com.

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

YES

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

YES

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

YES

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

YES

Do you have a bone or joint problem that could be made worse by a change in your physical activity? (Examples: back, hip or knee) *

YES

Is your doctor currently prescribing drugs for your blood pressure or heart condition? *

YES

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

YES

If you answered YES to any of the above questions please describe in more detail as to why you answered YES.

"I have read, understood and completed the questionnaire. By selecting 'Agree' it will act as my signature on this questionnaire." *

Full name *

Date signed *

YYYY

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