Physical Activity Readiness Form

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Par-Q Form

Name:
Date:
Phone:
Date of Birth:
Age:
Height:
Weight:
In Case of Emergency Contact:
Relationship:
Address:
Phone:
Physician:
Specialty:
Phone:
Address:

Are you currently under a doctor’s care:
If yes, explain:

When was the last time you had a physical examination?

Have you ever had an exercise stress test:
If yes, were the results:

Do you take any medications on a regular basis?
If yes, please list medications and reasons for taking:

Have you been recently hospitalized?
If yes, explain:

Do you smoke?
Are you pregnant?
Do you drink alcohol more than three times/week?
Is your stress level high?
Are you moderately active on most days of the week?

Do you have:

High blood pressure?
High cholesterol?
Diabetes?
A heart attack?
A stroke?
High blood pressure?
High cholesterol?
Known heart disease?
Rheumatic heart disease?
A heart murmur?
Chest pain with exertion?
Irregular heart beat or palpitations?
Lightheadedness or do you faint?
Unusual shortness of breath?
Cramping pains in legs or feet?
Emphysema?
Other metabolic disorders (thyroid, kidney, etc.)?
Epilepsy?
Asthma?
Back pain: upper, middle, lower?
Other joint pain (explain on back of form)?
Muscle pain or an injury (explain on back of Form)?

To the best of my knowledge, the above information is true.

Signature
Date

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