1. Has your doctor ever said that you have a heart condition OR high blood pressure? *

Yes

No

2.Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? *

Yes

No

3. Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *

Yes

No

4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *

Yes

No

5.Are you currently taking any prescribed medications? *

Yes

No

6. Do you have a bone or joint problem that could be made worse by becoming more physically active? Please answer NO if you had a joint problem in the past, but it does not limit your current ability to be physically active. For example, knee, ankle, shoulder or other. *

Yes

No

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

Yes

No

Name *

First Name

Last Name

Date *

MM

DD

YYYY

Signature *

By signing this PAR-Q, I 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.

Signature