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NAME:_________________________________________ DATE:_________________
HEIGHT:_________in.
PHYSICIANS NAME:____________________________
PHYSICAL ACTIVITY READINESS
1 Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
2 Do you feel pain in your chest when you perform
3 In the past month, have you had chest pain when you were not performing any physical activity? 4 Do you lose your balance because of dizziness or do you ever lose consciousness? 5 Do you have a bone or joint problem that could be made worse by a change in your physical activity? 6 Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? 7 Do you know of any other reason why you should not engage in physical activity? If you have answered “Yes” to one or more of the above questions, consult your physician engaging in physical activity. Tell your physician 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.
Data Collection Sheet
NAME:_________________________________________ DATE:_________________
WEIGHT:___________lbs. AGE:__________
PHYSICIANS NAME:____________________________ PHONE:_____________
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)
Questions Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any
Do you lose your balance because of dizziness or do you ever lose
joint problem that could be made worse by a change in
Is your doctor currently prescribing any medication for your blood pressure or
other reason why you should not engage in physical
If you have answered “Yes” to one or more of the above questions, consult your physician engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your
NAME:_________________________________________ DATE:_________________
AGE:__________
PHONE:_____________
Yes No
If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your
GENERAL & MEDICAL QUESTIONNAIRE
Occupational Questions
1 What is your current occupation?
______________________________________________________________
2 Does your occupation require extended periods of sitting
3 Does your occupation require extended periods
please explain.)
4 Does your occupation require you to wear shoes with a heel (dress shoes)
5 Does your occupation cause you anxiety (mental stress)
Recreational Questions 6 Do you partake in any recreational activities ( yes, please explain.)
7 _________________________________________________________________ 8 Are you physically active on a regular basis? Please estimate how many minutes per week you currently exercise (walking, jogging, sports, or other activity) 0-30minutes/week 60-90minutes/week 30-60minutes/week 90-120minutes/week
9 Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.)
Medical Questions
8 Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)
(If yes, please explain.)
9 Have you ever had any surgeries
_________________________________________________________________
_________________________________________________________________
10 Has a medical doctor ever diagnosed you with a chronic disease, such as
coronary heart disease, coronary artery disease,
blood pressure), high cholesterol or diabetes
________________________________________________________________
________________________________________________________________
11 Are you currently taking any medication
________________________________________________________________
________________________________________________________________
________________________________________________________________
QUESTIONNAIRE
Occupational Questions ?
Does your occupation require extended periods of sitting?
Does your occupation require extended periods of repetitive movements? (If yes,
_________________________________________________________________
Does your occupation require you to wear shoes with a heel (dress shoes)?
Does your occupation cause you anxiety (mental stress)?
Recreational Questions Do you partake in any recreational activities (dance, basketball, walking, etc)? (If
Are you physically active on a regular basis? Please estimate how many minutes per week you currently exercise (walking, jogging, sports, or other activity) 90minutes/week 120-150minutes/week 120minutes/week 150+ minutes/week
Do you have any hobbies (reading, gardening, working on cars, exploring the Internet,
________________________________________________________________
_________________________________________________________________
Medical Questions
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?
_________________________________________________________________
_________________________________________________________________
Have you ever had any surgeries? (If yes, please explain.)
_________________________________________________________________
_________________________________________________________________
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.)
________________________________________________________________
________________________________________________________________
medication? (If yes, please list.)
________________________________________________________________
________________________________________________________________
________________________________________________________________
Yes No
Yes No
Yes No
