Want Us To Contact You? Back Continue Submit We will be in touch shortly. NASM Par-Q Form Leave this field blank Name Date 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
