PAR-Q Form: Name * First Name Last Name Date * MM DD YYYY DOB * MM DD YYYY Height * Weight * Health Care Provider * Phone * (###) ### #### Has your health care provider ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when performing physical activity? * Yes No Have you experienced chest pain when NOT performing physical activity in the last month? * Yes No Do you lose your balance because of dizziness or have you lost consciousness recently? * Yes No Do you have any bone or joint problems (back, knee, hip, etc.) such as arthritis, which could be aggravated through physical activity? * Yes No Is your doctor currently prescribing you medications for high blood pressure or a heart condition? * Yes No Is there any reason why you should not participate in physical activity? * Yes No Reason (if you selected yes above) Do you currently exercise on a regular basis (3+ times per week)? * Yes No If you answered yes to any question, please explain. If you answered no to all questions, please acknowledge here. Do you agree that by submitting this document, this will take the place of your signature. * I agree Thank you!
