Online PAR-Q Form Creator
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Physical Activity Readiness Questionnaire(PAR-Q)
| # | Questions | Yes | No |
|---|---|---|---|
| 1 | Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? |
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| 2 | Do you feel pain in your chest when you perform physical activity? |
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| 3 | In the past month, have you had chest pain when you were not performing any physical activity? |
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| 4 | Do you lose your balance because of dizziness or do you ever lose consciousness? |
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| 5 | Do you have a bone or joint problem that could be made worse by a change in your physical activity? |
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| 6 | Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? |
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| 7 | Do you know of any other reason why you should not engage in physical activity? |
If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
GENERAL & MEDICAL QUESTIONNAIRE
| # | Occupational Questions | Yes | No |
|---|---|---|---|
| 1 | What is your current occupation? |
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| 2 | Does your occupation require extended periods of sitting? |
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| 3 | Does your occupation require extended periods of repetitive movements? (If yes, please explain.) |
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| 4 | Does your occupation require you to wear shoes with a heel (dress shoes)? |
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| 5 | Does your occupation cause you anxiety (mental stress)? |
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| # | Recreational Questions | Yes | No |
|---|---|---|---|
| 6 | Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.) |
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| 7 | Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.) |
| # | Medical Questions | Yes | No |
|---|---|---|---|
| 8 | Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.) |
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| 9 | Have you ever had any surgeries? (If yes, please explain.) |
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| 10 | Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.) |
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| 11 | Are you currently taking any medication? (If yes, please list.) |