fd-985.pdf

FD-985 ( 5-13-08)

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

Before beginning the Physical Fitness Test (PFT), please answer the seven questions below. The Physical Activity

Readiness Questionnaire (PAR-Q) will tell you if you should check with your doctor before you participate in the PFT or begin a physical fitness program. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly.

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? G Yes G No

2. Do you feel pain in your chest when you do physical activity? G Yes G No

3. In the past month, have you had chest pain when you were not doing physical activity? G Yes G No

4. Do you lose your balance because of dizziness or do you ever lose consciousness? G Yes G No

5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? G Yes G No

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? G Yes G No

7. Do you know of any other reason why you should not do physical activity? G Yes G No

If you answered YES to one or more questions:

Consult with your doctor BEFORE you participate in the PFT or BEFORE you start a physical fitness program. Tell your doctor about the PAR-Q and the questions to which you answered YES.

If you answered NO to all questions:

If you honestly answered NO to all PAR-Q Questions, you can be reasonably sure you can:

* Take part in the PFT. This is an excellent way to determine your basic level of fitness. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you begin a physical fitness program.

* Start a physical fitness program. You should begin slowly and build up gradually.

Delay participating in the PFT or beginning a physical fitness program:

* If you are not feeling well because of a temporary illness such as a cold or a fever, or

* If you are or may be pregnant -- talk to your doctor first

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.

Printed Name: _________________________________________________

Signature: _____________________________________________________ Date: ________________

Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the above seven questions.