PARQ FORM

Name *

First Name

Last Name

Has your doctor ever said you have a heart condition or advised you only to do medically supervised activity? *

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

Is your doctor currently prescribing medication for your blood pressure or heart condition? *

YES

NO

Do you know of any other reason why you should not engage in physical activity? *

YES

NO