2018 PAR-Q+ ‘The Physical Activity Readiness Questionnaire for Everyone ‘The health benefits of regula physical activity are clear; more people should engage in physical activity everyday ofthe week Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor Of a qualed exercise profesional before becoming more physical activ. GENERAL HEALTH QUESTIONS Please read the 7 questions below carefully and answer each one honestly: check YES or NO. Ps =| 1) Has your doctor ever said that you have a heart condition C) OR high blood pressure 1)? 2) De you fel pinn your chest ret, during your daly activites of ving, OR when you do physical activity? 3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO ifyour dizziness was assocated with over-breathing (including during vigorous exercise). 4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? PLEASE LIST CONDITION(S) HERE: 5) Are you currently taking prescribed medications for a chronic medical condition? PLEASE LIST CONDITION(S) AND MEDICATIONS HERE: 6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, butit does not mit your current ability to be physically active. PLEASE LIST CONDITION(S) HERE: 7) Has your doctor ever said that you should only do medically supervised physical activity? (of you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3. @ - Startbecoming much more physically active -start slowly and build up gradually. © Follow international Physical Activity Guidelines for your age (wwn.who.int/cietphysicalactivitylen/. @ You may take part in a health and fitness appraisal. Ifyou are over the age of 45 yrand NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise © professional before engaging inthis intensity of exerese. 7 ® _ Hfyou have any further questions, contacta qualified exercise professional. PARTICIPANT DECLARATION Hyouare [ess than the legal age required for consent or require the assent ofa car provides, your parent, guardian or cae provider must also sign this form. 4 he unde signed have read, understood to my fl satisfaction and completed ths questionnaire | acknowledge that this physical actty ‘learance is valid for a maximum of 12 months from the date its completed and becomes invalid if my condition changes. ‘acknowledge that the community/ftness centre may retain a copy of this form for records. In these instances, it will maintain the ‘onidentiality of the same, complying with applicable aw. NAME SIGNATURE ‘SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER DATE WITNESS, if you answered YES to one or more of the qu ove, COMPLETE PAGES 2 AND 3. Ai Delay becoming more active if: ‘You have a temporary iliness such asa cold or fever itis best to walt until you feel better. ate pggrant. tlk toyour f r-your physician, a qual ci sional, and/or co Ypgareergorar ta toyour heath cre pragttioner you asian a qualified execs professional andor complete the heath changes -anewer the questions on Fages 2and3 of this document and/or ‘ako your doctor ora qualified exercise professional betore continuing with any physical actvty program. Goro ieneer meme 1/4 ovt20172018 PAR-Q+ FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S) Do you have Arthritis, Osteoporosis, or Back Problems? Ifthe above condition(s) is/are present, answer questions 1a-1c 'tNOC) go to question 2 Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? YES) NOC) (Answer NO ifyou are not currently taking medications or other treatments) ‘Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, Supaced weteor (eg, spondyolsthes) anclorspondyohasparsdefec(a cack mie bony ang onthe YES) NOC) Satkor the spinal column? Have you had steroid injections or taken steroid tablets regulary for more than 3 months? ves) no) Do you currently have Cancer of any kind? Ifthe above conditions) is/are present, answer questions 22-26 1tNoD) goto question 3 ‘Does your cancer diagnosis include any ofthe fllowing types: lung/bronchogenic, muitple myeloma (cancer of plasma celsyheag,ana/or neck? Behe mies ves) no) ‘Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)? vesQ) noC) Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm Ifthe above condition(s) is/are present, answer questions 32-34 ttNoD goto question 4 ‘Do you have diffculty controlling your coneition with medications or other physician-preseibed therapies? Yes) No\ GeSner NO you ae not cent taksng mesiatons or oft wesimens “si OO ‘you have an regular heart beat that eques medal management? vs0) wo (e.g, atrial fibrillation, premature ventricular contraction) OO Do you have chronic heart failure? ves] Nol) De you have diagnosed corgnary artery (ordiovascle) disease and have not partcpated in regular physical scitnytntnelaas montis aricpaedinregur physical yes) so) - 2 Do you have High Blood Pressure? If the above condition(s) is/are present, answer questions 4a-4b ttNo OQ) go to question 5 Do you have ficult controling your colton wth medications o ther physidan-prescribed therapies? rdier NO you are not curesty taking medcatons or thertesmentsh "i ves #00 = 1Doyou Rave a extng blood pressure equa to or greater than 160/90 mmig with or without medication? (Answer ¥ES if you de not kriow your resting blood pressure) ves) NOQ) s Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes Ifthe above conditions) is/are present, answer questions 5a-Se HNO) goto question 6 Doyou often have difcuty controlling your blood sugar levels with foods, medications orother physican- yes) No) prederbed therapies? Do you often sufer from signs and flow blood ycemia folowing exerse andor during atvtis of daly oa sa Physic ia may indude shakines nervousness unusual wrtablty, yes). oC) SEnoralsvating azsness or ight headedhess, mental confusion dificult speaking, weakness, or sleepiness. ‘Do you have any signs or symptoms of diabetes complications such as hear or vascular disease and/or Contato ating your yes aaneys ON te seston n your toes a eet ves oO ‘Do you have other metabolic conditions (such as current pregnancy related dlabetes, chronic kidney disease, or liver problems)? vesQ 100 ‘Are you planning to engage in what for you is unusually high (or vigorous) intensity exercisein thenear future? ESC) NOC) Coigrozieringe tambon 2/4 0-1-20172018 PAR-Q+ 6 Doyou have any Mental Health Problems or Learning Difficulties? This includes Alzheimers, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome Ifthe above condition(s) is/are present, answer questions 62-6 1fNOD) go to question 7 62. __Doyouhave dificult controling your condition with medications r other physiclan-prescribed therapies? ESC) No} Gainer tyou a not carety taking medcavens orother restart) Loins 6b. Doyouhave Down Syndrome AND back problems affecting nerves or muscles? vesQ) no) Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure Ifthe above condition(s) is/are present, answer questions 72-74 1fNO OD) go to question 8 7a. Doyou have dificuity cantaling your condition with medications o other physilan-prescrbed therapies? thrdwerN you are not curesty taking medcaonsorothertretments) ws0 100 7b. Hasyourdoctor ever said your blood oxygen levels low at rest or during exercise and/or that you require ves() nol] supplemental oxygen therapy? 7e, asthmatic do you currently have symptoms of chest tightness, wheezing laboured breathing, consistent cough ves) oC) (more than 2 days/week) oF have you Used your rescue medication more than twice in the last week? 7A. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs? YES) NOD) 8. Doyouhave a Spinal Cord Injury? This includes Tetraplegia and Paraplegia If the above condition(s) is/are present, answer questions 82-8 1fNOD go to question 9 83, Doyouhave difficulty controlling your condition with medications or other physcian-prescibed therapies? tardwar WO tyou a notcunstty taking medealonsor other etment =O “0 85. Do you commonly exhibit lw resting blood pressure significant enough to cause dizziness, ight headedness, dlerSintngt Bondpressure 9 s vs wo) ‘8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic fas your phy 7 igh blood pres vesQ nol) 9. Have you hada Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event If the above condition(s) is/are present, answer questions 9a-9c IfNO D) goto question 10 92. Doyouhave difficulty controlling your condition with medications or other physcian-prescribed therapies? Carder NS tyou a notcunerty taking meiealonsor other ewnent vs0 wo) 9b, Doyou have any impairmentin walking or mobility? vesQ) Nol) 3c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months? vesO NOX) 10. Doyouhave any other medical condition not listed above or do you have two or more medical conditions? tes have other medical conditions, answer questions 10a-10c 1fNO (read the Page 4 recommendations 102. erlenced a blackout, fainted, or lost consciousness asa result ofa head injury within thelast 12 ves) nol) mrontte OR have ounads cagrosed concusion wrtnn heart 12 ontat 10b._Doyou havea medical condition that isnot listed (such as epilepsy, neurological conditions kidney problems)? YES) NOL) Yc. Do you currently lve with two or more medical conditions? vs no) PLEASE LIST YOUR MEDICAL CONDITION(S) [AND ANY RELATED MEDICATIONS HERE: GO to Page 4 for recommendations about your current medical condition(s) and sign the PARTICIPANT DECLARATION. Cpyight © 2018 PIRD® Calaboaton 3/4 ovt1-20172018 PAR-Q+ (Af fyou answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, sp Youre ready to become more physically active sign the PARTICIPANT DECLARATION below: Itis advised that you consult a qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs, Your pte encouraged to start slowly and bulld up gradually -20 to 60 minutes of low to moderate intensity exercise, 3°5 days per week including aerobic and muscle strengthening exercises. ‘As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. Ifyou are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a ualified exercise professional before engaging in this intensity of exercise. @ Ifyou answered YES to one or more of the follow-up questions about your medical condition: You should seek further information before becoming more physically active or engaging ina fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed:-X+ at www.eparmedx.com and/oi visita qualified exercise professional to work through the ePARmed-X+ and! for further information. ‘Ay Delay becoming more active if: You have a temporary illness such as a cold or fever; itis best to wait until you feel better. You are pregnant talk to your heath care practiont your pysican 2 qualifed exercise professional, and/or complete the ePARmed:-X+ at www.eparmedx.com before becoming more physically active. Your health changes - talk to your doctor or qualified exercise professional before continuing with any physical activity program. © You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted. (© The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. Ifin doubt after completing the questionnaire, consult your doctor prior to physical activ PARTICIPANT DECLARATION ‘@ All persons who have completed the PAR-Q+ please read and sign the declaration below. © Ifyou are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form. |, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. | acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid ifmy condition changes. | also acknowledge that the community/fitness center may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. NAME DATE ‘SIGNATURE WITNESS. SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER For more information, please contact ‘The PAR-Q wes created using the evidence-based AGREE process (1) by the PAR-Q+ cmaitsparmedycom Celaoraton cated by Dr. Daren E Warburton wth De Norman Gli Dz Veronica cncantarna, _mall-eparmeti@gmalcom Jai and Donald ten Podutonf hs document has been made pore Tere Sienetemamscsmncnemateersarcteene | though tmancal onions tone Pblc Heath Agency of Canada the BC insty ESSE SSS Sr reece St” | ath sevens thevens cpremed man owe ecient these the Soncmer beat Agency of acc Bey el Sevces mice titra ir ned aint poco intents ASS. 2 ene Gehrels et ee ar oer creat pacar ovr re nse Oise esl Oso pati es sc alia {Sn aay ote sen sala oso ean arlene RAI ME pyght © 2018 PIR Calaborton 4 / 4 ov-t1-2017