Name *

First Name

Last Name

Age

18-25

26-35

36-45

45-54

55 and Over

Phone Number *

(###)

###

####

Emergency Contact Number *

(###)

###

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Survey

I am committed to achieving my Health and Fitness Goals in 2019

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Has your doctor 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 you perform physical activity? *

Yes

No

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

Yes

No

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

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

Yes

No

Are you pregnant or have you had a baby in the last six months? *

Yes

No

Do you know of any other reason why you should not engage in physical activity? *

Yes

No

*

If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. If you answered "No" honestly to all PAR-Q questions, you can be reasonably sure that you can: A) Start becoming much more physically active. Begin slowly and build up gradually. This is the safest and easiest way to go. B) Take part in a fitness appraisal. 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 much more physically active

I have read, understood and completed this PAR-Q form

All questions have been answered to the best of my knowledge

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