PAR-Q sheet
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ABCDEF
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1055 Kalo Place, Suite 102
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Honolulu, HI 96826
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Phone: (808) 392-4816
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Email: chinone_a@yahoo.com
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ASSESSMENT FORM
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Last Name:Date of Birth:
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First Name:Age:
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Address:Occupation:
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Home Phone:Married or Single
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Cell Phone:Children under ten:
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Email:Children over ten:
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Primary Goal:Height:
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Sex:
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Physical Activity Readiness Questionnaire (PAR-Q)
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1. Has a doctor ever said you have a heart condition and recommended only medically supervised physical activity?YESNO
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2. Do you have chest pain brought on by physical activity?
YESNO
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3. Do you tend to lose consciousness or fall over as a result of dizziness?YESNO
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4. Has a doctor ever recommended medication for your blood pressure or a heart condition?YESNO
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5. Do you have a bone or joint problem that could be aggravated by the proposed physical activity?YESNO
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6. Are you aware through your own experiences or a doctor's advice of any other physical reason against your exercising without medical supervision?YESNO
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7. Are you over the age of 65 and not accustomed to vigorous exercise?YESNO
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8. Have you consulted your physician regarding increasing your physical activity and/or performing any exercise?YESNO
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Medical History: Please check all conditions that apply (been diagnosed)
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Heart Disease or StrokeGallbladder Disease
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High Blood PressurePsychological Problems
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CancerJoint Problems
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Lung/Pulmonary Disease (Difficulty Breathing)Osteoporosis
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Kidney/Liver DiseaseParkinson's Disease
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Stomach ProblemsRheumatoid Arthritis
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Gastrointestinal DiseaseAnorexia
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DepressionBulimia
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DiabetesChronic Pain
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Arthritis
Infectious Diseases (i.e. Hepatitis, HIV, TB)
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Food Allergies confirmed by a physicianHead Injuries
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Other AllergiesEpilepsy/Seizures
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Neuromuscular DiseaseThyroid Problems
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ArteriosclerosisOthers:
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Your Lifestyle
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1. What time do you go to sleep?
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2. What time do you get up?
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3. What do you do in your leisure/spare time?
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4. Do you exercise regularly?What do you do?
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5. What is your stress level 1-10 (10 is the highest)
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6. What is your learning method?VisualAudioKinetic
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7. Have you played any sports in the past?
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8. Are you currently in a sport team?
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9. Please list and describe any accidents and/or injuries you have had in the past.
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10. Did you have any rehab for injuries listed above?
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11. Please list any surgeries (with dates) you have had or may be scheduled to have.
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12. Are you currently taking any prescription or OTC medications?
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13. Do you get tired quicker than your friends/teammates during exercise?
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14. Do you have any skin problems? (i.e. itching, rash, warts, staph, etc)
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15. Do you have frequent or severe headaches?
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16. Have you ever been knocked unconscious or lost memory?
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17. Have you ever had numbness or tingling in your arms, hands, legs or feet?
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18. Have you ever had a stinger or pinched nerve?
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19. Do you smoke cigarettes or cigars?
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20. Do you have asthma?
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21. Do you have seasonal allergies that require medical treatment?
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22. Do you wear any special protective or corrective equipment or devices not usually used for your sport or position? (i.e. knee braces, neck rolls, hearing aids, pace maker, etc)
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23. Have you had any problems with your eyes or vision?
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24. Does your job, activity, or sport require you to lose weight regularly to meet weight requirements?
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25. Why is your goal important for you?
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26. Do you have any time frame to achieve your goal?
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27. Who supports your goal?
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28. What do you want to do after you reach your goal?
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29. (Females) Have you ever missed your menstrual cycle?
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30. (Females) Have you ever given birth?NaturalC-Section
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FOR OFFICE USE ONLY:
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Date:
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Program:
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Special Considerations or Restrictions:
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