PAR-Q (Simple) Date:* MM slash DD slash YYYY First Name:* Last Name:* Street Address: City: State /Province/Region: Zip/Postal Code: Email:* A copy of this form will be sent to this email address.Phone:*Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender:* Female Male Height (ft)InchesWeightAgeHas your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Yes No Do you feel pain in your chest when you perform physical activity? Yes No In the past month, have you had chest pain when you were not performing any physical activity? Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? Yes No Do you know of any other reason why you should not engage in physical activity? Yes No If you have answered “Yes” to one or more of the above questions, please consult your physician before engaging in physical activity. Inform your physician to which questions you answered “Yes.” After a medical evaluation, seek advice from your physician as to what type of activity is suitable for your current condition.Signature:Captcha Δ
