PAR-Q

Physical Activity Readiness Questionnaire

Regular activity is part of a healthy, balanced lifestyle. If you are planning to become more physically active, start by answering the following questions. Individuals of any age should check with their doctor before beginning a fitness program. This questionnaire is designed for people aged 15 to 70.

First name*

Last name*

Birthday*

Month

Day

Year

Email*

Phone*

Please answer the following questions honestly with a Yes or a No.

Has your doctor ever diagnosed you with a heart condition and told you to only do physical activity they can supervise?*

Yes

Does your doctor currently prescribe you drugs for your blood pressure or heart condition?*

Yes

Do you feel chest pain during physical activity?*

Yes

Do you lose your balance due to dizziness, or have you lost consciousness in the last 12 months?*

Yes

Do you have a bone, joint, or soft tissue problem that may be irritated by physical activity?*

Yes

In the past 30 days, have you had chest pain at any point?*

Yes

Do you have any other reason not to do physical activity?*

Yes

If you answered YES to one or more questions, talk to your doctor BEFORE you begin physical activity and BEFORE completing any fitness assessments. Discuss the questions you answered YES to with your doctor. Find out what activity you are cleared to partake in and any next steps your doctor wishes you to take.

If you answered NO honestly to all PAR-Q questions, you may: become more physically active; start slowly and build up gradually, take part in fitness assess, and/or consult with a fitness professional for guidance.

SIGN and SUBMIT this form back to SYRV Fitness.

"I have read, understood to my satisfaction, and completed this questionnaire. I acknowledge that my fitness professional may retain a copy of this form for their records and it will be kept with confidentiality in compliance with applicable laws."

Signature*

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Date of Submission*

Month

Day

Year

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