ParQ Form

The Physical Activity Readiness Questionnaire for Everyone

The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.

General Health Questions

1) Has your doctor ever said that you have a heart condition OR high blood pressure ?

Yes

2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

Yes

3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

Yes

4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

Yes

please list conditions and medications here:

5) Are you currently taking prescribed medications for a chronic medical condition?

Yes

Please list all conditions and medications here:

6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it doe

Yes

Please list conditions here:

7) Has your doctor ever said that you should only do medically supervised physical activity?

Yes

If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION at the end of this form. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

By inputting your name you declare the following: I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

If you answered YES to one or more of the questions above, COMPLETE the following. If you answered NO to the above questions please scroll to the bottom and press submit.

Do you have Arthritis, Osteoporosis, or Back Problems?

Yes

If yes, Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Or Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

Do you currently have Cancer of any kind?

Yes

If yes, Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/o Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?

Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm

Yes

If yes, Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction)

If yes, Do you have chronic heart failure? Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

Do you currently have High Blood Pressure?

Yes

If yes, Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?

Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes

Yes

If yes, Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician- prescribed therapies? Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

If yes, do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living?Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness

If yes, Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet? Do you have other metabolic conditions?

Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome

Yes

If yes, Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Do you have Down Syndrome AND back problems affecting nerves or muscles?

Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure

Yes

If yes, Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

If yes, If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough YES NO (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

If yes, Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia

Yes

If yes, Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?

If yes, Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?

Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event

Yes

If yes, Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Do you have any impairment in walking or mobility?

Do you have any other medical condition not listed above or do you have two or more medical conditions?

Yes

If yes, Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months? Do you have a medical condition that is not listed?

If you answered NO to all of the FOLLOW-UP questions about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

It is advised that you consult a qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a fitness appraisal.

Delay becoming more active if:

You are currently experiencing a temporary illness, such as a cold or fever. It is best to wait until you feel better.
You are pregnant. In this case, talk to your health care practitioner, physician, qualified exercise professional before becoming more physically active.
Your health changes. Talk to your health care practitioner, physician, or qualified exercise professional before continuing with any physical activity program.
You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted.

PARTICIPANT DECLARATION

All persons who have completed the PAR-Q+ please read and sign the declaration below.

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this

form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

First name

Last name

Participants Declaration

Signature

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Date and time

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Månad

Dag

Tid

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Phone

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