INTAKE FORM-PARQ – Rise Mind Body Facility

RISE MIND BODY FITNESS

TRAIN FOR LIFE. RISE ABOVE AVERAGE.

PARQ FORM: Physically Active Readiness Questionnaire

If you answer:

Yes to one or more questions

• Talk with your doctor by phone or in person before you start becoming much more physically active and before you have a fitness appraisal. Tell your doctor about the PAR-Q and which question(s) 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 advise.

“No” to all questions

• If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:

– Start becoming 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 fever – wait until you feel better.

• If you are pregnant – talk to your doctor before you start becoming more active.

• If your health changes so that you then answer YES to any of the above questions, consult your doctor.

Please ensure you SELECT [Y] for YES or [N] for NO.

Then make sure to sign by typing your name to confirm that you have read, understood and completed the questionnaire and any questions that you have were answered to your full satisfaction.

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

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

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

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

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?

6. Is your doctor currently prescribing drugs (ex. water pills) for your blood pressure or heart condition?

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

Full Name Of Participant

Date

Full Name Of Parent or Guardian (if applicable)

Date