Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you do physical activity? *

Yes

No

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

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

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

Yes

No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes

No

Do you know of any other reason why you should not do physical activity? *

Yes

No

Did you answer yes to any of the above questions? *

Talk with your doctor BEFORE you start becoming much more physically active. Tell your doctor about PAR-Q and which questions you answered yes. * You may be able to do any activity you want—as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you which to participate in and follow his/her advice. * If you answered NO to all PAR-Q questions honestly, you can be reasonably sure that you can: start becoming much more physically active—begin slowly and build up gradually. This is the safest and easiest way to go.

Yes

No

Do you belong to a membership gym?

Yes

No

Which of the following are most important to you? (select all that apply)

Fat loss

Building muscle

Strength

Speed, agility, quickness

Endurance

Sport (please name in question below)

Flexibility/mobility

Feel better/move better