Participate Activity Readiness Questionnaire
1. Has your doctor ever said you have a heart condition and that you should only perform
activity recommended by a doctor?
2. Do you feel pain in your chest when you do activity?
3. In the past month, have you had chest pain with activity?
4. Do you lose balance because of dizziness or do you ever lose consciousness?
5. Is your doctor currently prescribing drugs for your blood pressure or heart condition?
6. Do you have a bone or joint problem that could be made worse by a change
in physical activity?
7. Do you know of any reason why you should not do physical activity?
** If you are over 69 years of age, and you are not used to being very active, check with your doctor.
Medications
Name of Medication
AmountTaken For
1.
2.
3.
Do you have any medications that affect your heart rate?
If yes, please list.
If you are uncertain, please consult your doctor.
If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and to 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 that are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
- Find out which community programs are safe and helpful for you.
If you answered NO to all of the questions: If you answered NO honestly to all PAR-Q questions, 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.
- Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.
PLEASE NOTE:
If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.
DELAY BECOMING MUCH MORE ACTIVE:
- If you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better; or
- If you are or may be pregnant – talk to your doctor before you start becoming more active
I have reviewed these questions and answered them to the best of my ability. I understand the materials will be reviewed and I may be asked to see my doctor before participating in Activities.
Birthdate: Age:
Signature: Date:
Witness Signature:
