Name:

Preferred Name:

Preferred Pronouns:

Email:

Birth Date:

Height:

Weight:

Age:

Physician's Name:

Phone:

Is this a cell phone?

Yes
No

Address

Today's Date:

How did you hear about us?

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

Yes
No

2. Do you feel pain in your chest when you perform physical activity?

Yes
No

3. In the past month, have you had chest pain when you were not performing any physical activity?

Yes
No

4. Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes
No

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes
No

6. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

Yes
No

7. Do you know of any other reason why you should not engage in physical activity?

Yes
No

8. Are you taking beta blockers?

Yes
No

If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.