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PARQ+ Form

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Township of Wilmot
PAR-Q +

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.

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

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

Yes

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

Yes

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

Yes

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

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. You do not need to complete Pages the next group of questions

Start becoming much more physically active – start slowly and build up gradually
Follow International Physical Activity Guidelines for your age (www.who.int/dietphysicalactivity/en/).
You may take part in a health and ftness appraisal.
If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal efort exercise, consult a qualifed exercise professional before engaging in this intensity of exercise.
If you have any further questions, contact a qualifed exercise professional.

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/ftness centre may retain a copy of this form for records. In these instances, it will maintain the confdentiality of the same, complying with applicable law.

Name:

Date:

Signature:

Clear

Signature of Parent/Guardian/Care provider:

Clear

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PARQ+ Form

Township of WilmotPAR-Q +

GENERAL HEALTH QUESTIONS

PARTICIPANT DECLARATION

Township of Wilmot
PAR-Q +