Physical Activity Readiness Questionnaire for people aged 15 to 69
Regular Physical exercise is fun and healthy, and increasingly more people are starting to become more active every day.
Being more active is very safe for most people. However some people should check with their doctor before becoming physically active.

If you are planning to become much more physically active than you are now, start by answering the questions in the box below. 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 start. If you are over 69 and you are not used to being physically active, always check with your doctor.

Common sense is your best guide when you answer these questions.

Data Protection: The information that is provided on this form will be used by your trainer to plan your programme and to contact you. It will be kept on a computer database, accessible only to the trainer and her administrative assistant. In addition we request your permission below to add your name and email address to our database and to send you regular email newsletters. You will be able to unsubscribe from those newsletters at any time. Your name and email address will never be shared with any third party.

Date *
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Name *
Your answer
Address *
Your answer
Phone number
Your answer
Email *
Your answer
Do you give your consent for us to send you regular newsletters by email? *
Emergency Contact *
Your answer
1. Has your doctor ever said that you have a heart condition, and that you should only do physical activity recommended by a doctor? *
2. Do you feel pain in your chest when you do physical activity? *
3. In the past month, have you had chest pain when you were not doing physical activity? *
4. Do you lose your balance because of dizziness or do you ever lose consciousness? *
5: Do you have a bone or joint problem that could be made worse by your physical activity? *
6. Is your doctor currently prescribing you drugs (eg. water pills) for your blood pressure or heart condition? *
7. Do you know of any other reason why you should not do physical activity? *
8. Are you over 55 and not accustomed to vigorous exercise? *
9. Have you ever been diagnosed with Type I or type II Diabetes? *
10. Do you have any reason to suspect that you might be pregnant now, or have you been pregnant within the last 3 months? *
11. Have you had any major or minor surgery in the last 3 months? *
12. Have you been hospitalised in the last 2 years? If so, when and for what reason? *
13. Are you currently, or have you in the past ever seen a chiropractor or physiotherapist for any condition? If yes, when and for what condition? *
14. Do you ever experience unexpected shortness of breath or laboured breathing, with or without pain? If yes, describe under what conditions? *
15. Do you currently, or have you ever, experiences unexplained heart palpitations, or been diagnosed with a heart murmur or irregular heartbeat? *
16. Have you ever been disagnosed with high blood pressure? If yes, when ? *
17. Do you know what your blood pressure normally is. If yes, please state it below
Your answer
18. Do you currently smoke? If yes, how many cigarettes a day? *
Your answer
19. Is there any history of heart disease prior to age 55 in your immediate family? If yes, please give details *
If you have answered yes to any of questions 1-19 above, please supply details *
Your answer
. Do you have any pain, discomfort , or known current or previous injury to any of the following areas? *
Yes
No
Right or left shoulder
Right or left Elbow
Right or left knee
Right or left wrist
Right or left ankle
Right or left hip
Back or neck
If you checked yes to any of the above please explain the site and nature of your injury. Do certain activities or conditions aggravate the pain or injury? *
Your answer
Are there any other health/medical/injury conditions that your trainer should be aware of? *
Your answer
Please list any prescription medications, over the counter medications or supplements that you currently take *
Your answer
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