PAR-Q (Physical Activity Readiness) Questionnaire & Informed Consent Form

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Name:

Age?

18-24

25-34

35-44

45-54

55-60

60+

Do you have any medical condition and can only perform exercise recommended by a doctor?

YES

If answered yes, please explain:

This is required

Do you lose balance because of dizziness or have been unconscious?

YES

If answered yes, please explain :

This is required

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

YES

Comments:

This is required

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

YES

If answered yes, please explain:

This is required

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

YES

If answered yes, please explain

This is required

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

YES

If answered yes, please explain:

This is required

Do you give informed consent to voluntarily taking part in any exercise proscribed by the trainer

Yes, I Consent

Do you agree to the PT Terms and Conditions set?

Yes, I agree

* Print Name for Signature.

Required

This is required

Page 1

Name:

Age?

Do you have any medical condition and can only perform exercise recommended by a doctor?

Do you lose balance because of dizziness or have been unconscious?

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

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 a heart condition?

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

Do you give informed consent to voluntarily taking part in any exercise proscribed by the trainer

Do you agree to the PT Terms and Conditions set?