Client Readiness for Exercise
Name *
Date *
Age *
Email *
Physical Activity Readiness Questionnaire (PAR-Q)
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *
Do you feel pain in your chest when you perform physical activity? *
In the past month, have you had chest pain when you were not performing any physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
 Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *
Do you know of any other reason why you should not engage in physical activity? *
General and Medical History
What is your current occupation? *
Does your occupation require extended periods of sitting? *
Does your occupation require you to wear shoes with a heel? *
Does your occupation require repetitive movements? If YES, please explain) *
Does your occupation cause you mental stress? *
Do you partake in any recreational physical activities (golf, skiing, etc.)? If YES, please explain.
Do you have any additional hobbies (reading, video games, etc.)? If YES, please explain.
Have you ever had any injuries or chronic pain? If YES, please explain.
Have you ever had any surgeries? If YES, please explain.
Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? If YES, please explain.
Are you currently taking any medication? If YES, please explain.
Additional Information
Is there anything else Coach Sue should know about?
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