Par-Q | The Exercise Hub

First name

Last name

Email

Phone

Birthday

Month

Day

Year

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

Yes

No

Have you ever felt pain in your chest when you do physical exercise?

Yes

No

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

Yes

No

Do you often feel faint, have spells of severe dizziness or have lost consciousness?

Yes

No

Have you ever suffered from unusual shortness of breath at rest or with mild exertion?

Yes

No

Has the doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or that may be made worse by exercise?

Yes

No

Do you have either high or low blood pressure. If yes, which type?

Yes

No

High

Low

Are you currently on any prescribed medicines that may affect your ability to exercise?

Yes

No

Are you pregnant or have you had a baby in the last 6 months (females only)?

Yes

No

Do you know of any other reason that would affect your ability to participate in physical activity?

Yes

No

Is there any health or mobility related information we may need to know before you start Exercise? (Injuries, Allergies, Asthma etc...)

If you answered YES to one or more questions:

Talk to your doctor either in person or by phone before you start becoming more physically active and/or taking a fitness appraisal. Tell your doctor what questions you answered yes to on this form.

You may still be able to do any activity you want as long as you start slowly and build up gradually or it may be that you need to restrict your activities to those which are safe for you.

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