Please fill out the following information as thorough as possible.




Height (inches):

Weight (pounds):


Emergency Contact:

Contact's Phone:

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?yesno

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

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

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

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

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

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

If you have answered "yes" to one or more of the above questions, consult your physician before engaging in physical activity. Tell your doctor 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.

Occupational Questions

1. What is your current occupation?

2. Does your occupation requires extended periods of sitting? Describe.

3. Does your occupation requires extended periods of repetitive movements? Describe.

4. Does your occupation requires you to where shoes with a high heel or dress shoes?

5. Does your occupation cause you anxiety, mental or emotional stress?

Recreational Questions

6. Do you partake in any recreational activities? (golf, tennis, walking, running, etc.)

7. Do you have any hobbies? If so, what are they?

Medical Questions

8. Have you ever had any pain or injuries (ankle, knee, back, hip, shoulder, etc.? If yes, please explain.

9. Have you had any surgeries? If yes, please explain.

10. 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.

11. Are you currently taking any medications? If so, please list.

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