BeHealthConscious PAR-Q & Readiness Screening

Disclaimer: This questionnaire is not medical advice. If you answer yes to any medical screening question, seek physician clearance before beginning or increasing exercise.

Full name

Phone

Date of birth

Month

Day

Year

Emergency contact name

Emergency contact phone

Has a physician ever said you have a heart condition and should only do medically recommended physical activity?

Yes

Do you feel chest pain during physical activity?

Yes

In the past month, have you had chest pain when not doing physical activity?

Yes

Do you lose balance because of dizziness or ever lose consciousness?

Yes

Do you have a bone or joint problem that could worsen with exercise?

Yes

Are you currently prescribed medication for blood pressure or a heart condition?

Yes

Is there any other reason you should not participate in physical activity?

Yes

Details or explanation

I confirm that my answers are accurate and I understand that this form does not replace medical advice.

Typed signature (full name)

Date

Created with

BeHealthConscious PAR-Q & Readiness Screening

Disclaimer: This questionnaire is not medical advice. If you answer yes to any medical screening question, seek physician clearance before beginning or increasing exercise.

Full name

Phone

Date of birth

Month

Day

Year

Emergency contact name

Emergency contact phone

Has a physician ever said you have a heart condition and should only do medically recommended physical activity?

Yes

Do you feel chest pain during physical activity?

Yes

In the past month, have you had chest pain when not doing physical activity?

Yes

Do you lose balance because of dizziness or ever lose consciousness?

Yes

Do you have a bone or joint problem that could worsen with exercise?

Yes

Are you currently prescribed medication for blood pressure or a heart condition?

Yes

Is there any other reason you should not participate in physical activity?

Yes

Details or explanation

I confirm that my answers are accurate and I understand that this form does not replace medical advice.

Typed signature (full name)

Date

Created with

BeHealthConscious PAR-Q & Readiness Screening