PAR-Q Physical Activity Readiness Questionnaire. OptiMum Health and Fitness for Women
This PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. Common sense is your best guide when answering these questions. Please read carefully and answer each one honestly. This information is strictly confidential.
Sign in to Google to save your progress. Learn more
Email *
Current date
MM
/
DD
/
YYYY
Name *
Address
Phone number *
Date of birth
MM
/
DD
/
YYYY
 Emergency contact name and number *
Reason for wanting to participate in this exercise programme?
Current exercise regime?
Previous exercise experience?
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Clear selection
Do you feel pain in your chest when you do physical activity?
Clear selection
In the past month have you had chest pain when you were not doing  physical activity?
Clear selection
Do you lose balance because of dizziness or do you ever lose consciousness?
Clear selection
Do you have a bone or joint problem? ( for example back, knee or hip) that could be made worse by a change in physical activity?
Clear selection
Is you doctor currently prescribing medication for your blood pressure or heart condition?
Clear selection
Have you previously or do you still suffer from any of the following?
Do you smoke? ( if yes how many daily)
Clear selection
Do you currently have any injuries?
Clear selection
Please give more details of injury below
Are you on any medication?
Clear selection
If so which medication?
Have you had surgery of any kind in the last 12 months?
Clear selection
If you answered YES to one or more questions : You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.                                                                                    NO to all questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.
Are you pregnant?
Clear selection
Have you had a baby in the last 6 months?
Clear selection
If you have EVER had a baby (even 50 years ago) please complete the following question. If not please move on to the next question.  (This is so I can make sure the exercises and advice given are appropriate)
Do you currently or have you ever suffered any of the following conditions?
Please give more information if you answered yes to any of the above or if you wish to share more detail on the birth and how that impacted you.
Do you know of any other reason why you should not take part in physical activity?  If yes, please comment.
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury. Please sign and date.
Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise. Please sign and date.
Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the  questions. Please inform your trainer of any changes.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms