Par-Q    Physical Activity Readiness Questionnaire
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First Name: *
Last Name: *
1) Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? *
Required
2) Do you frequently have pains in your chest when you perform physical activity? *
Required
3) Have you had chest pain when you were not doing physical activity? *
Required
4) Do you lose your balance due to dizziness or do you ever lose consciousness? *
Required
5) Do you have a bone, joint or any health problem that causes you pain or limitations that must be addressed when developing an exercise program ( i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, epilepsy, respiratory ailments, back problems, etc.)? *
Required
6) Are you pregnant now or have you given birth within the last six months? *
Required
7) Have you had recent surgery? *
Required
8) If you marked YES to any of the above questions please elaborate below. *
If none marked yes please write NONE.
9) Do you have any chronic illness such as diabetes or asthma? *
Required
10) Do you have any injuries or orthopedic problems such as bursitis, bad knees,back, shoulder,wrist, or neck issues?
If Yes please explain below
11) Do you take any medications, either prescription or non-prescription,on a regular basis?
If Yes please list medications below.
12) How does this medication affect your ability to exercise or achieve your fitness goals? *
If None please write NONE
13) Do you smoke? *
Required
14) Do you drink alcohol? If so how many glasses a week? *
15) How many hours of sleep do you regularly sleep? *
16) Describe your job: *
17) Does your job require travel? *
Required
18) On a scale of 1 to 10,  how would you rate your stress level ( 1=very low, 10 =very high) *
19) List your three biggest sources of stress: *
20) Is anyone in your family overweight?
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21) Were you overweight as a child? *
Required
By Initialing I acknowledge that the above information is correct and I have read and understood the questions above. *
Please initial Below
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