Savage Strength PAR-Q
Physical Activity Readiness Questionnaire.

This form requires you to answer every question. If a box is not applicable such as the boxes that ask 'if yes please detail' then just write 'N/A' in the box.

The information in this form is confidential, will not be divulged to any other party, will only be discussed with you and is for internal use only.
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Name: *
Date of Birth: *
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Age *
Height *
Weight *
Occupation *
Which of the following options best describes your activity level? *
Does your job require travel? *
Do you smoke? *
If yes how many per day? Please detail below: *
Do you drink alcohol? *
If yes how much per week? Approximate weekly units: *
On average how many hours of sleep do you get per night? *
Hours
Hours
If less than 7 hours what are the biggest things that get in the way of sleep? *
How would you rate your stress levels? (1=very low, 10=very high) *
Very Low
Very High
List your 3 biggest sources of stress: *
Were you overweight as a child? *
Is anyone in your family overweight? *
Please list any pathologies and injuries (disabilities, allergies, illnesses, syndromes, disorders etc.) you have or had. *
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? *
Do you frequently have pains in your chest when you perform physical activity? *
Have you had chest pain when you were not doing physical activity? *
Do you lose your balance due to dizziness or do you ever lose consciousness? *
Are you pregnant now or have you given birth within the last 6 months? *
Have you had a recent surgery? *
If you have marked YES to the above, please give details below: *
Have you been diagnosed with any mental health conditions? *
If you have marked YES to the above, please give details below: *
Do you have any diagnosed mental health issues recently? E.g. Depression or Anxiety? *
If you have marked YES to the above, please give details below: *
. Do you have any undiagnosed mental health issues recently? E.g. Depression or Anxiety? *
If you have marked YES to the above, please give details below: *
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc)? *
If you have marked YES to the above, please give details below: *
Do you have any other medical issues that haven't been listed? *
If you have marked YES to the above, please give details below: *
Do you take any medications, either prescription or non-prescription, on a regular basis? *
If you have marked YES to the above, please give details below: *
I have answered these questions honestly and to the best of my knowledge. *
Signed (Type your name): *
Date Signed: *
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