← BackYour form has been submitted Name(required) Age(required) Date (YYYY-MM-DD)(required) Phone(required) Height(required) In Cm Weight(required) Lbs Kg Physician’s Name Physician’s Phone 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? Yes No In the past month, have you had chest pain when you were not performing any physical activity? Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No Do you know of any other reason why you should not engage in physical activity? Yes No Do you feel pain in your chest when you perform physical activity? Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? 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. General & Medical Questionnaire What is your current occupation? Does your occupation require extended periods of sitting? Yes No Does your occupation require extended periods of repetitive movements? (If yes, please explain.) Yes No Does your occupation require you to wear shoes with a heel (dress shoes)? Yes No Does your occupation cause you anxiety (mental stress)? Yes No Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.) Yes No Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.) Yes No Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.) Yes No Have you ever had any surgeries? (If yes, please explain.) Yes No Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.) Yes No Are you currently taking any medication? (If yes, please list.) Yes No SendSubmitting form Δ
