PAR Q

Name*

First Last

Email*

Age*

Height*

Date of birth*

Contact Number*

Emergency Contact Name*

Emergency Contact Number*

Doctors Name*

Doctors Address/ Contact Number*

Activity Level*

Please select the statement that best describes your current activity level:

Sedentary - Little to no exercise. Inactive in both work and leisure
Lightly active - Intensive exercise for at least 20 minutes once or twice per week or daily routine includes some walking. Example: student. Generally you do not exercise regularly, but you maintain a busy life style that requires you to walk frequently for long periods
Moderately active - Intensive exercise for at least 20 to 45 minutes 3 to 4 times per week or a job with a lot of walking, or a moderate intensity job.
Very active - Intensive exercise for 60 minutes or greater 5 to 7 days per week. Labour-intensive occupations also qualify for this level. Labour-intensive occupations include construction work (brick laying, carpentry, general labour, etc.). Also, farming, landscape worker or similar occupations
Extremely active - Exceedingly active and/or very demanding activities: Examples include: athlete with an almost unstoppable training schedule with multiple training sessions throughout the day or a very demanding job, such as shovelling coal or working long hours on an assembly line. Generally, this level of activity is very difficult to achieve

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 doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, please start by answering the questions below. If you are between the ages of 16 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are under the age of 16 or over 69 years of age, and you are not used to being very active, please check with your doctor first. For anyone under the age of 16, this form must be completed by a parent/guardian. Common sense is your best guide when you answer these questions.

Please read the questions on the next page carefully and answer each one honestly:

1. Are you currently under a doctors care?*

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

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

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

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

6. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?*

7. Is your doctor currently prescribing any medication for your blood pressure, high cholesterol or a heart condition?*

8. Have you ever suffered from a stroke?*

9. Are you diabetic?*

10. Do you suffer from asthma or any other respiratory conditions*

11. Have any relatives ever suffered from any of the above conditions?*

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

13. Do you smoke?*

14. Are you pregnant or recently had a baby?*

15. Do you drink alcohol more than three times per week*

16. Is your stress level high?*

Disability

The Disability Discrimination Act 1995 defines a disabled person as anyone with a ‘physical or mental impairment that has a substantial and long-term adverse effect upon his/her ability to carry out normal day-to-day activities’.

Do you consider yourself to have a disability?*

If yes, what is the nature of your disability?

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 which questions you answered YES to. 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 wish to participate in and follow his/her advice.

If you answered NO honestly to all 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. Taking part in a fitness appraisal is an excellent way to determine your basic health and fitness level. It is also highly recommended to have your blood pressure evaluated. Please speak to your instructor who can arrange these for you. If your blood press reading is over 140/90 please talk with your doctor before you start becoming much more physically active.

Delay becoming much more active:

If you are not feeling well because of temporary illness such as a cold or fever, wait until you feel better. If you are pregnant or are within 6 weeks of giving birth, talk to your doctor before you start becoming more active.

Please note:

If your health changes so that you then answer YES to any of the above questions, tell your instructor and ask whether you should change your physical activity plan.

Disclaimer*

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

Name

This field is for validation purposes and should be left unchanged.

Disability

If you answered YES to one or more questions:

If you answered NO honestly to all questions

Delay becoming much more active:

Please note:

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