Par - Q & You Parent Questionnaire Template printable pdf download

PAR – Q & YOU

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active everyday. 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, start by answering

the seven questions in the box below. 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 start. If you are over 69 years of age, and you are not used to being very active, check with your

doctor. Common sense is your best guide when you answer these questions.

Please read the questions carefully and answer each one honestly: IF any answer is YES , PLEASE elaborate and

tell us your situation. We want you to be safe and successful! A doctors note is all that is needed to be able to

exercise. Please print out this form and get it signed by your doctor at your next checkup and submit to the gym.

Thanks!

Has your doctor ever said that you have a heart condition and 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?

Do you have a bone or joint problem that could be made worse by a change in your

Physical activity?

Is your doctor currently prescribing drugs (for example, water pills) for your blood

Pressure or heart condition?

Do you know of any other reason why you should not do physical activity? If so, explain:

___________________________________________________________________________________________________________________________

IF YOU ANSWERED

STOP HERE – IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS- you will need to PRINT this

DOCUMENT and bring it with you to your next CHECK-UP to get DOCTOR consent to exercise.

Doctors office must complete a Medical Release form, and return back to Ravenswood Fitness Center – Before you can begin an exercise program.

Date:_______________ DOCTOR Signature:____________________________________________

Member Signature______________________________

___—

YES to 1 question AND I have visited the doctor recently…

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.

• 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.

NO to all questions

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure 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 live actively.

•

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.

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.

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

Name _______________________________________________

Date __________________

Signature ____________________________________________

Witness ________________