Zak Nordyke Holistic Fitness PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q) Common sense is your best guide when

you answer these questions. Please read the questions carefully and answer each one honestly: choose YES or NO. YES NO 1. Has a doctor ever said you have a heart condition and recommended only medically supervised physical activity? YES NO 2. Do you have chest pain brought on by physical activity? YES NO 3. Have you developed chest pain within the past month? YES NO 4. Do you tend to lose consciousness or fall over as a result of dizziness? YES NO 5. Do you have a bone or joint problem that could be aggravated by the program? YES NO 6. Has a doctor ever recommended medication for your blood pressure or a heart condition? YES NO 7. Are you aware, through your own experience or a doctor's advice, of any other physical reason which should limit or prevent you from exercising without medical supervision? If you answered yes to one or more of the previous questions, exercise testing and training sessions should be postponed and medical clearance should be sought. Talk with your doctor by phone or in person BEFORE you start the program. Tell your doctor about this survey and which questions you answered YES. I have read, understood and completed this questionnaire. All questions were answered to my full satisfaction. Medical History Smoking (within the last year) High Blood Pressure (> 140/90) History of Heart Disease (personal) History of Heart Disease (family) Diabetes (personal) Diabetes (family) Elevated Cholesterol (> 240 mg/dl) Heart Murmur Arrhythmia Pain or discomfort in chest

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No

Have you ever had difficulty breathing? If so, please explain:

Yes

No

Have you ever experienced fainting or dizzy spells? If so, please explain:

Yes

No

Have you been injured recently? If so, please explain:

Yes

No

Are you currently taking any medication? If so, please explain:

Yes

No

Is there any condition that might limit your participation in an exercise program? If so, please explain:

Yes

No

ATHELETES ONLY What sports will you be training for? What position or event? What are your goals in your sport? (Please be as specific as possible) Are you currently exercising? If so, please explain: Yes No

When does your sport season begin? I have read, understood, and completed this questionnaire. All questions were answered to my full satisfaction. Name:

First

Middle

Last

Address:

Street or PO Box

City

State

Zip Code

Date of Birth: XX/XX/XXXX Home Phone: E-Mail: Physician:

Height:

Weight:

Gender (M/F):

Work Phone: SSN: XXX-XX-XXXX Primary Hospital:

Parent or Guardian Name:

Signed:_____________________ Participant

Date _____/_____/_____

_____________________(Parent of Guardian, if under 18)