PAR-Q - TO KINESIOLOGY

PAR-Q (PHYSICAL ACTIVITY READINESS QUESTIONNAIRE)

Full Name*

First NameLast Name

Your date of birth*

Your phone number*

Please read the following questions carefully and check (X) next to the appropriate answers. Answer all questions honestly and to the best of your ability.

YES/ NO*

	Yes	No
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Are you pregnant now or have given birth within the last 6 months?
Have you had a recent surgery?
Are you currently on any medications, either prescription or non-prescription, on a regular basis?

If you have answered 'Yes' to any of the above, please elaborate below:

Today's Date*

Date

Signature of Participant:*