PARQ+

The Physical Activity Readiness Questionnaire for Everyone

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 you to seek further advice from your doctor

OR a qualified exercise professional before becoming more physically active.

Section 1: General Health Questions

Please read the 7 questions below carefully and answer each one honestly: Check YES or NO

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

Yes

If yes, which one:

Heart Condition

High Blood Pressure

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

Yes

3. Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?

Yes

Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

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

Yes

If yes, please list conditions here:

5. Are you currently taking prescribed medications for a chronic medical condition?

Yes

If yes, please list condition(s) and medication(s) here:

6. 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

Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.

If yes, please list condition(s) here:

7. Has your doctor ever said that you should only do medically supervised physical activity?

Yes

If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION at the bottom of this page. You do not need to complete Section 2.

If you answered YES to one or more of the questions above, CONTINUE TO COMPLETE SECTION 2.

Delay becoming more active if:

You are currently experiencing a temporary illness, such as a cold or fever. It is best to wait until you feel better.
You are pregnant. In this case, talk with your health care practitioner, physician, qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.
Your health changes. Answer the questions on remaining sections of this document and/or talk to your health care practitioner, physician, or qualified exercise professional before proceeding with any physical activity program.

Section 2: Follow Up Questions About Your Medical Condition(s)

1. Do you have Arthritis, Osteoporosis, or Back Problems?

Yes

If No, go to the next question. If Yes, answer the following:

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Leave blank if you are not currently taking medications or other treatments)

Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer,

displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the

back of the spinal column)?

Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

2. Do you have Cancer of any kind?

Yes

If No, go to the next question. If Yes, answer the following:

Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of

plasma cells), head, and/or neck?

Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?

3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm.

Yes

If No, go to the next question. If Yes, answer the following:

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Leave blank if you are not currently taking medications or other treatments)

Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction)

Do you have chronic heart failure?

Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

4. Do you currently have High Blood Pressure?

Yes

If No, go to the next question. If Yes, answer the following:

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Leave blank if you are not currently taking medications or other treatments)

Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Check if you do not know your resting blood pressure)

5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes.

Yes

If No, go to the next question. If Yes, answer the following:

Do you often have diffculty controlling your blood sugar levels with foods, medications, or other physician prescribed

therapies?

Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.

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?

Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?

Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

6. Do you have any Mental Health Problems or Learning Diffculties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome

Yes

If No, go to the next question. If Yes, answer the following:

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Leave blank if you are not currently taking medications or other treatments)

Do you have Down Syndrome AND back problems affecting nerves or muscles?

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure

Yes

If No, go to the next question. If Yes, answer the following:

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Leave blank if you are not currently taking medications or other treatments)

Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

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?

Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia

Yes

If No, go to the next question. If Yes, answer the following:

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?(Leave blank if you are not currently taking medications or other treatments)

Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?

Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic

Dysreflexia)?

9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event

Yes

If No, go to the next question. If Yes, answer the following:

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Leave blank if you are not currently taking medications or other treatments)

Do you have any impairment in walking or mobility?

Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

10. Do you have any other medical condition not listed above or do you have two or more medical conditions?

Yes

If No, go to the next question. If Yes, answer the following:

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?

Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?

Do you currently live with two or more medical conditions?

Please list medical conditions(s) and medication(s) here:

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 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,3-5 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 yr 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 or more of the FOLLOW-UP questions (Section 2) 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 are currently experiencing a temporary illness, such as a cold or fever. It is best to wait until you feel better.
You are pregnant. In this case, talk to your health care practitioner, physician, qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.
Your health changes. Talk to your health care practitioner, physician, or qualified exercise professional before continuing with any physical activity program.

You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted.

The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire, consult your doctor prior to physical activity.

PARTICIPANT DECLARATION

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.

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 community/witness center 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.

I agree to the participant declaration stated above

First name

Last name

Signature

Signature field is empty.

Date

Month

Day

Year

*Note: The PARQ+ Form is an industry standard form for Personal Training.

This form is a digital version from: https://eparmedx.com/?page_id=79

PARQ+

PARQ+

Get in Touch

Have questions or comments? Contact us today!

Email: info@motivatedbymovement.com
Phone: (503) 395-5323

PARQ+

PARQ+

Get in Touch

Have questions or comments? Contact us today!

Email: info@motivatedbymovement.com Phone: (503) 395-5323

Email: info@motivatedbymovement.com
Phone: (503) 395-5323