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Physical Activity Readiness Quesitonnaire (PAR-Q)

The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for your to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.

General Health Questions

Has your doctor ever said that you have a heart condition OR high blood pressure?
Yes
No
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?
Yes
No
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
Yes
No
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
Yes
No
Are you currently taking prescribed medications for a chronic medical condition?
Yes
No
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?
Yes
No
Has your doctor ever said that you should only do medically supervised physical activity?
Yes
No

If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION (by filling in your first and last name below). You do not need to complete Sections 2 and 3.

Start becoming much more physically active - start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the Off Grid Health, Fitness, & Outdoors may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

If you are less than the legal age required for consent or require the assent of a parent, guardian, or care provider must also sign this form.

If you are less than the legal age required for consent or require the assent of a parent, guardian, or care provider must also sign this form.

Date
Month
Day
Year

Follow-Up Questions About Your Medical Condition(s)

1. Do you have arthritis, osteoporosis, or back problems?
Yes
No

If yes, answer questions 1a-1c.

1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
Yes
No
1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra, and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?
Yes
No
1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?
Yes
No
2. Do you currently have cancer of any kind?
Yes
No

If yes, answer questions 2a-2b.

2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic multiple myeloma (cancer of plasma cells), head, and/or neck?
Yes
No
2b. Are you currently receiving cancer therapy?
Yes
No
3. Do you have a heart or cardiovascular condition? This includes coronary artery disease, heart failure, diagnosed abnormality of heart rhythm.
Yes
No

If yes, answer questions 3a-3d.

3a. Do you have a difficulty controlling your condition with medications or other physician-prescribed therapies?
Yes
No
3b. Do you have an irregular heart beat that requires medical management?
Yes
No
3c. Do you have chronic heart failure?
Yes
No
3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?
Yes
No
4. Do you currently have high blood pressure?
Yes
No

If yes, answer questions 4a-4b.

4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
Yes
No
4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?
Yes
No
5. Do you have any metabolic conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes, etc.
Yes
No

If yes, answer questions 5a-5e.

5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?
Yes
No
5b. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living?
Yes
No

Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?
Yes
No
5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?
Yes
No
5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?
Yes
No
6. Do you have any mental health problems or learning difficulties? This includes Alzheimer's, dementia, depression, anxiety disorder, eating disorder, psychotic disorder, intellectual disability, down syndrome, etc.
Yes
No

If yes, answer questions 6a-6b.

6a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
Yes
No
6b. Do you have down syndrome AND back problems affecting nerves or muscles?
Yes
No
7. Do you have a respiratory disease? This includes chronic obstructive pulmonary disease (COPD), asthmas, pulmonary high blood pressure, etc.
Yes
No

If yes, answer questions 7a-7d.

7a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
Yes
No
7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?
Yes
No
7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, labored breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?
Yes
No
7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?
Yes
No
8. Do you have a spinal cord injury? This includes tetraplegia and paraplegia.
Yes
No

If yes, answer questions 8a-8c.

8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
Yes
No
8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?
Yes
No
8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as autonomic dysreflexia)?
Yes
No
9. Have you had a stroke? This includes transient ischemic attack (TIA) or cerebrovascular event.
Yes
No

If yes, answer questions 9a-9c.

9a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
Yes
No
9b. Do you have any impairment in walking or mobility?
Yes
No
9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?
Yes
No
10. Do you have any other medical condition not listed above or do you have two or more medical conditions?
Yes
No

If yes, answer questions 10a-10c.

10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?
Yes
No
10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems, etc.)?
Yes
No
10c. Do you currently live with two or more medical conditions?
Yes
No

If you answered NO to all of the FOLLOW-UP questions (Section 2) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION (by filling in your first and last name) below. 

It is advised that you consult a qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3 to 5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.

If you are over the age of 45 and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you answered YES to ONE MORE MORE OF THE FOLLOW-UP QUESTIONS about your medical condition:

You should seek further information before becoming more physically active or engaging in a fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

Delay becoming more active if:

You have a temporary illness such a sa cold or fever; it is best to wait until you feel better.

You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.

Your health changes - talk to your docotr or qualified exercise professional before continuing with any physical activity program.

PARTICIPANT DECLARATION

All persons who have completed the PAR-Q, please read and sign the declaration (by filling in your first and last name) below.

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian, or care provider must also sign this form. The participant should fill in their name first with "(participant)" entered after their name, then below, the parent/guardian/provider should fill in their name with "(parent/guardian/provider)" entered after their name.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the Off Grid Health, Fitness, & Outdoors may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

If you are less than the legal age required for consent or require the assent of a parent, guardian, or care provider must also sign this form.

Date
Month
Day
Year
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