Want Us To Contact You? Back Continue Submit We will be in touch shortly. NASM Par-Q Form Leave this field blank Name Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 Age Physical Activity Readiness Questionnaire (PAR-Q) 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 for a heart condition? YES NO Do you know of any other reason why you should not engage in physical activity? YES NO If you have answered YES to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered YES to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. General and Medical History Occupational What is your current occupation? Does your occupation require extended periods of sitting? Does your occupation require repetitive movements? (If YES, please explain.) YES NO Does your occupation require you to wear shoes with a heel (e.g., dress shoes)? YES NO Does your occupation cause you mental stress? YES NO Recreational Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.) YES NO Do you have any additional hobbies (reading, video games, etc.)? (If YES, please explain.) YES NO Medical Have you ever had any injuries or chronic pain? (If YES, please explain.) YES NO Have you ever had any surgeries? (If YES, please explain.) YES NO Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? (If YES, please explain.) YES NO Are you currently taking any medication? (If YES, please explain.) YES NO Additional Information Submit Book A Session
