Par-Q Patient Form printable pdf download

Par-Q Patient Form

PAR-Q Form

Name:

Date:

DOB:

Height:

Weight:

Health Care Provider:

Phone:

Questions

Has your health care provider ever said that you have a heart condition and

Yes

that you should only perform physical activity recommended by a doctor?

Do you feel pain in your chest when performing physical activity?

Yes

Have you experienced chest pain when NOT performing physical activity in

Yes

the last month?

Do you lose your balance because of dizziness or have you lost

Yes

consciousness recently?

Do you have any bone or joint problems (back, knee, hip, etc.) such as

Yes

arthritis, which could be aggravated through physical activity?

Is your doctor currently prescribing you medications for high blood pressure

Yes

or a heart condition?

Is there any reason why you should not participate in physical activity?

Yes

Reason:

Do you currently exercise on a regular basis (3+ times per week)?

Yes

If Yes to Any Questions:

If No to All Questions:

Name

Guardian Name

Par-Q Patient Form