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Physical Activity Readiness Questionnaire
Client Name
DOB
Address
Email
Phone Number
Emergency Contact Name and Contact Number
If you are between the ages of 15 and 69 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 the 69 years of age and are not used to being very active, check with your doctor. Please read each question carefully and answer honestly by indicating YES or NO .
I agree.
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 balance because of dizziness or do you ever lose consciousness?
YES
NO
5) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
YES
NO
6) Are you currently taking prescribed medications for a medical condition?
YES
NO
7) Do you have a bone or joint problem that could be made worse by becoming more physically active? Please answer NO if you had a joint problem in the past, but it does not limit your current ability to be physically active. For example, knee, ankle, shoulder or other.
YES
NO
If YES please comment:
Data Protection: The information from the PAR-Q will be stored in line with the General Data Protection Regulation 2018 (GDPR). This information will be stored in electronic format on a secured computer and will be required to be reviewed annually for any changes. Anyone not using this service for 12 months this information will be archived. This information will be held up to 7 years and then destroyed.
I agree.
I give permission for photos/videos to be used on social media for promotion purposes.
YES
NO
Signed
Date
Send
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