Par-Q and Health History Form
Personal Information
Full Name
Date of Birth
Email Address
Phone Number
Address
Physical Activity Readiness Questionnaire (Par-Q)
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No
2. Do you feel pain in your chest when you do physical activity?
Yes
No
3. In the past month, have you had chest pain when you were not doing physical activity?
Yes
No
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes
No
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Yes
No
7. Do you know of any other reason why you should not do physical activity?
Yes
No
Health History
Have you ever been diagnosed or treated for any of the following?
Heart Disease
High Blood Pressure
Stroke
Asthma
Diabetes
High Cholesterol
Arthritis
Osteoporosis
Back Pain
Surgery
Injury
Other (please specify)
Current Medications
List any medications you are currently taking
Lifestyle
How often do you currently exercise per week?
What are your fitness goals?