Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has your doctor ever said that you have a heart condition or that you should only do 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 doing 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

s your doctor currently prescribing medication for your blood pressure or a heart condition?

Yes

No

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

Yes

No

Emergency Contact

First Name

Last Name

Phone

(###)

###

####

Please Tick the box to declare that you have have read, understood, and completed this PAR-Q and that all questions I had were answered to my full satisfaction.

I declare that the statement above is true.

Today's Date

MM

DD

YYYY