PARQ+

Chris Weber NASM-CPT

Specializing

Senior

Fitness

Par Q Pre-exercise Assessment Form

Name *
Phone *
Email *
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
	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 performing any 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 any medication for your blood pressure or a heart condition?
	Yes
	No
Do you know of any other reason why you should not engage in physical activity?
	Yes
	No

Be sure to check only one box per question

It is important to answer all questions as accurately as possible

If you have additional information for a question please provide in the text box associated to the question.