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PARQ
Physical Activity Readiness Questionnaire
Email address *
Basic information
Full Name: *
Your answer
Date of birth:
MM
/
DD
/
YYYY
Height:
Your answer
Weight:
Your answer
Sex:
Major risk factor identification
Yes
No
Don't know
Do you have diabetes?
Are you clinically obese?
Is your TOTAL cholesterol to HDL cholesterol ratio greater than 5 to 1
Have you ever had an abnormal exercise ECG?
Do you have a history of high blood pressure?
Do you have a family history of coronary or other atherosclerotic disease prior to age 50?
Personal medical history
Have you ever suffered:
Yes
No
Heart attack
Had bypass surgery
Cardiac surgery
Extreme chest discomfort
High blood pressure over 145/95
Over 35 and smoke
Serum cholesterol over 240mg/dcl
Irregular heart beat
Heart murmurs
Rheumatic fever
Ankle swelling
Any vascular disease
Phlebitis
Unusual shortness of breath
Fainting
Asthma, emphysema, or bronchitis
Abnormal blood fat levels
Stroke
Emotional disorders
Recent illness, or hospitalisation
Drug allergies
Orthopaedic problems, or arthritis
Do you currently have any illness, injury or limitations?
If yes, please give details:
Your answer
Are you currently on any medication?
If yes, please give details:
Your answer
General information
On average, how many hours of QUALITY sleep to you get a night?
Your answer
On average, how many litres of water/liquid do you consume in a day?
Your answer
What is your current occupation?
Your answer
How would you rate your current stress levels?
Not stressed
Extremely stressed
Goal setting
If possible, list 3 goals for each section
Short term goals / 8-12 weeks
Your answer
Medium term goals / 6-9 months
Your answer
Long term goals / 12+ months
Your answer
Exercise history
Are you currently following an exercise plan of any kind?
If yes, please give details
Your answer
When was the last time you have exercised on a regular basis?
Your answer
Please list your least favourite exercises:
Your answer
Please list your favourite exercises:
Your answer
Eating habits
Please list the foods and drinks you consume on a TYPICAL day. Please provide times and answer honestly.
Breakfast:
Your answer
Snack:
Your answer
Lunch:
Your answer
Snack:
Your answer
Dinner:
Your answer
Snack:
Your answer
Please list the foods and drinks you consume on a BAD day. Please provide times and answer honestly.
Breakfast:
Your answer
Snack:
Your answer
Lunch:
Your answer
Snack:
Your answer
Dinner:
Your answer
Snack:
Your answer
Confirmation and consent
I confirm that I have answered all questions honestly, truthfully and to the best of my knowledge. *
I hereby give consent to ‘Stephan Konrad’ to perform additional screening assessments which may include the pinching of skin with a body fat calliper, measuring the circumference of various body parts with a tape measure and appropriate touching for postural and exercise form correction. *
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