PAR-Q - Lala's Life Garden

Physical Activity Readiness Questionnaire (PAR-Q)

Name *

First

Last

Email *

Date: *

Height: (in.) *

Weight: (lbs.) *

Age: *

Physicians Name & Phone: *

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Do you feel pain in your chest when you perform physical activity? *

In the past month, have you had chest pain when you were not performing any 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 any medication for your blood pressure or for a heart condition? *

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 why type of activity is suitable for your current condition. *

Agreed

We will provide you with a Doctor's Release form to bring to your medical evaluation if any of your above answers were "Yes". Once your Doctor has cleared you then we can proceed with training. *

Agreed

Name