PHYSICAL ACTIVITY READINESS QUESTIONNAIRE Today's Date * MM DD YYYY Name * First Name Last Name Age * Height * 4'10" 4'11" 5' 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6' 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" Weight (LBS) * Physician's Name Physician's Phone (###) ### #### Physical Activity Readiness Questionnaire (PAR-Q) 1) Has your doctor ever said that you have a heart condition OR high blood pressure? * YES NO 2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? * YES NO 3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? * YES NO 4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? * YES NO 5) Are you currently taking prescribed medications for a chronic medical condition? * YES NO 6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? * Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. YES NO 7) Has your doctor ever said that you should only do medically supervised physical activity? * YES NO Thank you for submitting the PAR-Q! If you have answered YES to one or more questions, please consult your doctor before engaging in physical activity. Tell them which questions you answered YES to, and after medical evaluation, seek advice on what type of activity suits your current condition. I will need clearance from your doctor before we can start personal training together.
