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PAR-Q
physical activity readiness questionnaire
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* Indicates required question
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
1.
Has your doctor ever said that you have a heart condition and recommended only medically supervised activity?
*
YES
NO
2.
Do you have chest pain brought on by physical activity?
*
YES
NO
3.
Have you developed chest pains in the last month
*
YES
NO
4.
Do you tend to lose consciousness or fall over as a result of dizziness?
*
YES
NO
5.
Do you have a bone/ joint problem or previous injury that could be aggravated by the proposed physical activity?
*
YES
NO
6.
Has a doctor ever recommended medication for blood pressure or a heart condition or do you take medication?
*
YES
NO
7.
Are you pregnant or have you been pregnant in the last 3 months?
*
YES
NO
8.
Do you know, through you own experience, or doctor’s advice, of any other physical reason why you should not exercise without medical supervision?
*
YES
NO
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.
If you answered NO to ALL of the questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.
Declaration
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.
Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise.
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