Physical Activity Readiness Questionnaire (PAR-Q)

Welcome!

Before starting this program, please take a few minutes to answer these questions honestly.Your answers help ensure the exercises are safe and appropriate for you. All information is kept confidential.

Full Name

Email

Phone Number ###-###-####

Date of Birth

Month

Day

Year

Emergency Contact Name

Emergency Contact Phone#

Are you currently taking any medication?

Yes

No

Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by exercise?

Yes

No

If yes, describe briefly

Has your doctor ever said 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

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

Yes

No

Is there any other reason why you should not do physical activity?

What are your goals for this program?

Agreement & Signature

By signing (or typing your name) below, you acknowledge that:

You have answered these questions truthfully to the best of your knowledge.
You understand that it’s your responsibility to consult your physician if you have any concerns about your readiness for physical activity.
You agree to stop exercising and seek medical advice if you experience any unusual pain, dizziness, or discomfort.
You understand this program provides general exercise instruction and does not replace medical advice or individualized physical therapy.

Signature

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