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About us
Services
Semi Private Training
Memberships
Body Tempering
in Body
Semi Private Athletic Training
Cold plunge
Powerlifting
Reviews
Contact
Contact Us
Training Questionnaire
Videos
Blog
More Info
FAQs
Minor Waiver
PARQ Questionnaire
Adult Waiver
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Physical Activity Readiness
PARQ
Questionnaire
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PARQ-Physical Activity Readiness Questionnaire
PARQ
PARQ-Physical Activity
Readiness Questionnaire
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Your details
Name
Date of Birth
*
Age
*
Sex
Male
Female
Health history
Have you had a heart attack, stroke, chest pain or heart surgery? Please specify:
Yes
No
Has your doctor said you have cardiovascular, pulmonary, metabolic or other significant disease?
Yes
No
During, or right after exercise, do you have pains or pressure in the chest area, neck, shoulder, or arms?
Yes
No
Have you experienced any unusual leg pain upon exertion?
Yes
No
Has your doctor said that you have a heart murmur or irregular heartbeat?
Yes
No
Do you have insulin dependent diabetes or take medication to control your blood sugar?
Yes
No
Do you experience shortness of breath at rest or with mild exertion?
Yes
No
Has your doctor said you have high blood pressure (140/90), or are you on medication for your blood pressure?
Yes
No
Do you experience dizziness/ fainting spells at rest or with exertion?
Yes
No
Are you currently pregnant or within six weeks post-partum? Number of months pregnant:
Yes
No
Are you currently taking prescription medication for an underlying disorder?
Yes
No
Do you have a chronic or acute orthopedic or other health condition that you or your physician feel will be affected by or affect your exercise (i.e. Bursitis, Arthritis, neck or back injury, past surgery, etc.)?
Yes
No
Please Specify
Do you have a medical condition, not previously mentioned, which might affect your ability to participate in an exercise program (i.e. seizures, Epilepsy, Emphysema, Asthma, etc.)?
Yes
No
Please Specify
Do you have a male family member under the age of 55, OR a female family member under the age of 65 who has a history of cardiovascular disease such as heart disease, stroke, angina (chest pain) high blood pressure, etc.?
Yes
No
Please Specify
Are you a male over the age of 45?
Yes
No
Are you a female over the age of 55, are post-menopausal, or have had a hysterectomy?
Yes
No
Do you consider yourself more than 20 lbs. overweight?
Yes
No
Is your total serum cholesterol > 200 mg/dl and/or have you been diagnosed with high cholesterol?
Yes
No
Do you use tobacco or have you used tobacco within the last 5 years? If yes, please circle one or more of the following: cigarettes cigar/pipe chewing tobacco
Yes
No
If yes, which one?
Do you currently have less than 3 days a week of physical activity?
Yes
No
Do you have any exercise limitations not previously discussed (i.e. recent injuries, etc.)?
Yes
No
If yes, please explain?
Medical information
When was your last physical exam?
Please list any cardiovascular, pulmonary or nervous system medications, as well as any related medications that could impact how the body responds to exercise.
Medication name
Purpose
Please list any other pertinent health/medical information we should be aware of:
I understand that this form is not intended as a substitute for consultation with my personal physician. I must consult my own personal physician for any evaluation of my health status. I certify that I have read and understand all questions on the health and exercise history questionnaire, and that all questions have been answered truthfully, to the best of my knowledge. I agree to notify Elite Fitness Training and Coaching if there are any changes in the information that I have provided herein.
Signature (Name)
Date
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