Orders

Additional Required Information

Physical Activity Readiness Questionnaire (PAR-Q)

Please fill in the questions below:

Age: *

Healthcare Provider: *

Being more active is very safe for most people, and for most should not pose any problem or hazard. However, some people should check with their doctor before they start becoming much more physically active.

Questions

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. If your condition changes throughout the exercise program such that you would answer “Yes” to any of these questions, consult your physician before continuing.

Occupational Questions

What is your current occupation? *

Does your occupation require extended periods of sitting?  * Yes No

Does your occupation require extended periods of repetitive movements? (If yes, please explain below)  *

Does your occupation require you to wear shoes with a heel (dress shoes)?  * Yes No

Does your occupation cause you anxiety (mental stress)? * Yes No

Medical Questions

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain below) *

Have you ever had any surgeries? (If yes, please describe below) *

Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please describe below) *

Are you currently taking any medication? (If yes, please describe below)  *

Have you delivered a child within the last 6 weeks? * Yes No

Was this vaginal birth? (Please speak to one of empowered fitness studio to give more details) * Yes No

Recreational Questions

Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please describe below)  *

Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please describe below)  *

I have read, understood, and completed this questionnaire to the best of my knowledge.  I understand that I am responsible for monitoring my own physical condition throughout the exercise program and should any unusual symptoms occur, I would cease my participation and notify my instructor of the symptoms. * Yes, I confirm

Signature *

Signature of Parent or Guardian (for participants under the age of 18) *

Please enter todays date *