Health Questionnaire/Par-Q

 

Please complete the form below

Name *
Name
Date *
Date
Address *
Address
Home Phone *
Home Phone
Cell Phone
Cell Phone
Physician's Phone *
Physician's Phone
Phone *
Phone
PART I (SYMPTOMS)
1. Has your doctor ever said you have heart trouble, heart palpitation, coronary disease, or high blood pressure? *
2. Do you frequently experience pain or discomfort in the chest or heart area? *
3. Do you suffer from shortness of breath at rest or upon mild exertion? *
4. Do you suffer from dizziness or fainting? *
5. Do you have any difficulty breathing? *
6. Do you suffer from swollen ankles (due to circulation problems or metabolic condition)? *
If “yes” is the answer to any of the above please have physician complete medical clearance form prior to exercise
PART II (RISK FACTORS)
1. Has a physician ever diagnosed you as having high blood pressure (>160/90), or are you on blood pressure medication? *
Is the value >240mg/dL? *
3. Do you smoke? If yes, how many cigarettes a day? *
4. Do you suffer from diabetes? *
5. Has anyone in your immediate family suffered from coronary or atherosclerotic disease prior to the age of 55 years? *
6. Are you now or do you think you may be pregnant?
If “yes” to two or more of the above please have physician complete medical clearance form prior to exercise
MEDICATIONS/LIMITATIONS/PAST MEDICAL HISTORY
Do you have any physical limitations that would limit your ability to exercise? *
SMOKING/PHYSICAL ACTIVITY/SELF IMAGE
Did you ever smoke? *
Are you now smoke free?
Do you consider yourself leading a stressful life? *
10 = most stressful
Do you practice stress management? *
I pledge that all the information which I have provided in this form is accurate, to the best of my knowledge, and that I have not willingly excluded any important medical information which could have any bearing on my ability to safely engage in exercise testing and exercise participation.
Signature of Participant: *
Signature of Participant:
Date *
Date
Signature of Trainer:
Signature of Trainer:
Leave Blank
Date
Date