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Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day.

Being more active is very safe for most people. However, some people should check with their physician before they

start becoming more physically active.

Please complete this form as accurately and completely as possible.

PAR-Q FORM Please mark YES or No to the following: YES NO

Has your doctor ever said that you have a heart condition and recommended

only medically supervised physical activity? ____ ____

Do you frequently have pains in your chest when you perform physical activity? ____ ____

Have you had chest pain when you were not doing physical activity? ____ ____

Have you had a stroke? ____ ____

Do you lose your balance due to dizziness or do you ever lose consciousness? ____ ____

Do you have a bone, joint or any other health problem that causes you pain or

limitations that must be addressed when developing an exercise program

(i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis,

anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? ____ ____

Are you pregnant now or have given birth within the last 6 months? ____ ____

Do you have asthma or exercise induced asthma? ____ ____

Do you have low blood sugar levels (hypoglycemia)? ____ ____

Do you have diabetes? ____ ____

Have you had a recent surgery? ____ ____

If you have marked YES to any of the above, please elaborate below:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Do you take any medications, either prescription or non-prescription, on a regular basis? Yes/No

What is the medication for?

How does this medication affect your ability to exercise or achieve your fitness goals?

__________________________________________________________________________________________________________________

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Please note: If your health changes such that you could then answer YES to any of the above

questions, tell your trainer/coach. Ask whether you should change your physical activity plan.

I have read, understood, and completed the questionnaire. Any questions I had were answered to my

full satisfaction.

Print Name: _________________________________Signature: _______________________________________

Date: _______________________________________