Physical Activity Readiness Questionnaire - PAR-Q -Cynsational Fitness

Physical Activity Readiness Questionnaire - PAR-Q

Please read and complete this PAR-Q before our first session.

First Name

Last Name

Phone Number

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.

If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you arebetween the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age,and you are not used to being very active, check with your doctor.

Common sense is your best guide when you answer these questions.

Please read the questions carefully and answer each one honestly.

Has your doctor ever said that you have a heart condition and that you should only do physical activities recommended by a doctor?

Yes

Do you feel pain in your chest when you do physical activity?

Yes

In the past month, have you had chest pain when you were not doing physical activity?

Yes

Do you lose your balance of dizziness or do you ever lose consciousness?

Yes

Do you have a bone or joint problem (i.e. back, knee, hip, shoulder, etc.) that could be made worse by a chance in your physical activity?

Yes

Is your doctor currently prescribing drugs for blood pressure or heart condition?

Yes

Do you know of any other reason why you should not do physical activity?

Yes

If you answered YES to one or more questions:

Talk with your doctor by phone or in person BEFORE you start becoming much more physically active.

You may be able to do any activity you want - as long as you start slowly and build up gradually.

Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish toparticipate in and follow his/her advice.

Find out which programs are safe and helpful for you.

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:

Start becoming much more physically active - begin slowly and build up gradually. This is the safest and easiest way to go. Take part in a fitnessappraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming muchmore physically active.

if you are not feeling well because of a temporary illness such as a cold or a fever - wait until you feel better; or if you are or may be pregnant - talk to your doctor before you start becoming more active.

Please note: If your health changes so that you then answer "YES" to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

Informed Use of the PAR-Q: Cynsational Fitness assumes no liability for persons who undertake physical activity, and if in doubt aftercompleting this questionnaire, consult your doctor prior to physical activity.

NOTE: If the PAR-Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section may be used for legal or administrative purposes.

“I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.”

I agree to the terms & conditions

Your Signature

Has your doctor ever said that you have a heart condition and that you should only do physical activities recommended by a doctor?

Yes