physquest

The PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and not used to being very active, check with your doctor.

Please read carefully and answer the following questions. If answering yes please give details in the space provided.

		YES	NO
1)	Has your doctor ever said you have a heart condition and that you should	□	□
	only do physical activity recommended by a doctor?
2)	Do you feel pain in your chest when you do physical activity?	□	□
3)	In the past month have you had chest pain when you were not doing	□	□
	physical activity?
4)	Do you lose your balance because of dizziness or do you ever lose	□	□
	consciousness?
5)	Do you have a bone or joint problem (for example back, knee, or hip)	□	□
	that could be made worse by a change in your physical activity?
6)	Is your doctor currently prescribing medication for your blood pressure	□	□
	or heart condition?
7)	Do you know of any other reason why you should not do physical	□	□
	activity?

	If yes, please provide any relevant information:_________________________________
	__________________________________________________________________________
	__________________________________________________________________________
	__________________________________________________________________________

YES to one or more questions: You should consult your doctor to clarify that it is safe for you to become physically active at this time and in your current state of health.

“I have read, understood and accurately completed this questionnaire. I conform that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.”

Clients name: _________________ Trainers Name: ________________

Signature: ____________________ Signature: ____________________

Date: ___________ Date: ___________