Physical Activity Readiness Questionnaire (PAR-Q)

If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Common sense is your best guide when answering these questions. Please read carefully and answer each one honestly: select YES or NO.

First name

Last name

Date of Birth required

Emergency Contact Name

Emergency Contact Number

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

Yes

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

Yes

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

Yes

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

Yes

5. 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?

Yes

6. Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes

7. Do you know of any other reason why you should not do physical activity?

Yes

If you answered 'Yes' to the last question, please provide detail below

If you answered: ‘Yes’ to one or more questions: You must consult your doctor before undertaking any fitness appraisal, workshop or other exercise routine. You will need to discuss the nature of the activity you are about to undertake and either present your PAR-Q or tell your doctor which questions you answered ‘yes’ to. Your doctor needs to advise you as to your suitability for unrestricted physical activity.

If you answered ‘No’ to all questions: You acknowledge that you are taking responsibility for the accuracy of your replies and the decision that you are physically fit enough for unrestricted physical activity.

Initials

Sessions may include physical activities such as running and stretching. Each part of the session will be fully explained to you but please ask questions if you are not clear about anything. Please notify the instructor if you feel you should not do a particular exercise for any reason. Exercise programmes contain certain risks such as muscle strains, joint sprains, aches, pains and general discomfort from parts of the body not used to exercise. The programme is designed to minimise these risks, however, if at any time during the exercise programme you feel pain, discomfort or you feel unwell you must stop and inform the instructor immediately.

i) By accepting this PAR-Q I undertake that I have read, understood and correctly answered the questions set out above.

ii) I wish to participate in activities that may include aerobic, anaerobic, flexibility, stability, resistance, muscular strength and endurance exercise.

iii) I realise that my participation in these activities involves the risk of injury and even the possibility of death.

iv) I confirm I am voluntarily engaging in a level of exercise that I consider acceptable and appropriate to my level of fitness.

v) If I have answered ‘Yes’ to any of the questions above, by signing this form I am also confirming that I have taken medical advice relating to my participation and my doctor has confirmed I am fit enough to participate.

I hereby confirm that I have read, understood and answered all the questions on the PAR-Q accurately and to the best of my knowledge. I confirm that I wish to participate in this running group and realise that the activities involve an element of risk of injury or even death.

Thanks for submitting

Physical Activity Readiness Questionnaire (PAR-Q)

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