2022 PAR-Q+ The Physical Activity Readiness Questionnaire for Everyone ‘The health benefits of regular physical activity are clear; more people should engage in physical activity every day ofthe week. Participating in physical activity is very safefor MOST people. This questionnaire will tll you whether itis necessary for you to seek further advice rom your dactor ORa qualified exercise professional before becoming more physically active. GENERAL HEALTH QUESTIONS Please read the 7 questions below carefully and answer each one honestly: check YES or NO. he 1) Has your doctor ever said that you have a heart condition (J OR high blood pressure)? 2)Do you feel pain in your chest at rest, during your daily activites ofliving, 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 if your dizziness was associated with over breathing (including duting 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) abone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming mote physically active? Please answer NO ifyou hac a problem inthe past, butt does not limit your current ability tobe physically active PLEASE LIST CONDITION(S) HERE: 7) Has your doctor ever said that you should only do medically supervised physical activity? og you answered NO toall ofthe questions above, you are dearedfor physical activity Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3. ® Star becoming much more physically active star slomly an buildup gradually: © Follow Global Physical Activity Guidelines for your age (httpsu/Auww.who int/publications/iiten/9789240015 128). @ Yournay take part ina health and fitness appraisal @ fyouareoverthe age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult qualified exercise professional Before engaging in ths intensty of exercise ®© tr youhave any further questions, contact a qualified exercise professional PARTICIPANT DECLARATION if you te lessthan the legal age required for consent orrequite the assent ofa care provider your parent, guardian or care provider must also sign this frm. the undersigned have ea understood to my ul satstacton and complete his questionnat|acknowldge that ths ysl activity clearance is valid fora maximum of 12 months from the date tis completed and becomes invalid if my condition changes. also acknowledge that the communityfitness center may retain a copy ofthis form forts records In these instances twill maintain the Confidentiality of the same, complying with applicable aw. NAME DATE SIGNATURE WITNESS SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER @ Ifyou answered YES to one or more of the questions above, COMPLETE PAGES 2 AND 3. Ay Delay becoming more active if: ‘You havea temporary illness such asa cold or fever it is best towealt until you ea! better. You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePaiimeg ES worm epatmadccom before becomng tore pHyscal ctve i hl You heath changes: ane the questions on Fages 2 and3 ofthis document andiortakto your doctor ora qualified exercise professional before continuing with any physical activity program. ‘Copyright 9 2021 PAFOH Colabuaton 1/4 1-11-20212022 PAR-Qt+ FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S) 1. Doyou have Arthritis, Osteoporosis, o Back Problems? If the above condition(s) is/are present, answer questions 1a-1c IfNOQ) go to question 2 Ta, Doyou have difficulty controlling your condition with medications or other physician-prescribed therapies? Yes) NOC), (nswer NOif you are not currently taking medications or other treatments) 1b. —_Doyou have int problems causing pan, a recent fracture o fracture caused by osteoporosis o cancer, cisplaced veitebra (ea, spondyloisthesis) and/or spondyllysis/pars defect (@crackin the bony ringon the YS) NOC), backofthespinal column)? Tc. Have you had steroid injections or taken steroid tabltsregulrly for more than 3 months? ves NoQ) 2 Doyou currently have Cancer of any kind? IF the above condition(s) is/are present, answer questions 22-26 tfNOO) go to question 3 22. Does your cancer diagnosis include any ofthe following types: lunarbronchogentc multiplemyeloma (ancerof YES) NoQ) plasma cells head, andor neck? 2. —_Areyou currently receiving cancer therapy (such as chemotheraphy or radiotherapy)? vesQ) Nol) 3, Doyou have Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm IF the above condition(s) is/ere present, answer questions 32-34, fNOD goto question 4 3a __Doyou have difficulty controling your condition with medications or other physician-prescrbed therapies? Yes) no() ‘Answer NOif you are not currently taking medications or other treatments} 3b. Do you havean irregular heart beat that requires medical management? yes) nol) (eg, atrial brillation, premature ventricular contraction} 3< —_Doyou have chronic hear failure? vesQ) nol) 3d. —_Doyyou have diagnosed coronary artery (cardiovascular) cisease and have not participated in regular physical activity in thelast2 months? ves) nol) = Doyou currently have High Blood Pressure? IF the above condition(s) is/are present, answer questions 43-4 1fNOO) go toquestion 5 4a, Do you have difficulty controling your condition with medications or other physician-prescrbed therapies? YES) No) (Answer NO f you are not curently taking medications or other treatments} 4b Do you havea resting blood pressure equal to or greater than 160/90 mmHg with or without medication? v0 noQ) (Answer YESif you do not know your resting blood pressure) Doyou have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes |F the above condition(s) is/are present, answer questions 5a-5e tfNOD) go to question 6 Sa. Doyowoften have cficuty controling your blood sugar levels with foods, medication orotherphysician- YES) No) prescribed therapies? 5b. Do you often sufferfrom signs and symptoms of low blood sugar hypoglycemia following exercise andor during activities of daly living? Signs of hypoglycemia may include shakiness nervousness, unusual iritabilty, yes) No) abnormal sweating, dizziness or ight-headedhess, mental confusion, difficulty speaking, weakness or sleepiness. 5c. Doyou have any signs or symtoms of diabetes complications such as heart or vascular disease and/or YEsE) nol) complications affecting your eyes kidneys, ORthe sensation in your toes and feet? 5d Doyouhave other metabolic conditions (uch as current pregnancy-elated diabetes, chronic kidney dsease,or yes) NOC) liver problems)? Se. Areyou planning to engage in what for you's unusualy high (or vigorous) intensity exercise inthe nearfuture? Yes) NOC) cho 2022 PAROS Coleberaton 2 / 4 1-11-20212022 PAR-Qt+ 6 Do you have any Mental Health Problems or Leaming Difficulties? This includes Alzheimer's, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome If the above condition(s) is/are present, answer questions 6a-6b 'fNOQ) go to question 7 6a Doyouhave diffculty controlling your condition with medications or other physican-prescribed therapies?’ ves) no) (@nsiver NO if you are not currently taking medications or other treatments) 6b. _Doyou have Down Syndrome AND back problems affecting nerves or muscles? vesQ) oQ) 7. Doyou havea Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure If the above condition(s) is/are present, answer questions 7a-7d 1fNOQ) go to question 8 7a Doyouhave difficulty contoing your condition with medications or other physician-prescribed therapies? gg) WoC) ‘(snswer NO you are not currently taking medications or other treatments) 75 Has your doctor ever said your blood oxygen level islow a rest or during exercise and/or that you require es) 10D) supplemental oxygen therapy? Te \fasthmatcd you curenty have symptoms of chest ightness, wheezing laboured breathing consistent OuSN yes) yo] (more than 2 days/week) or have you used your rescue medication more than twice inthe last week? 7d. Has your doctor ever aid you have high blood pressure inthe blood vessels of your lungs? vs] no) 8 Doyouhavea Spinal Cord Injury? This includes Tetraplegia and Paraplegia Ifthe above condition(s) is/are present, answer questions B@-8c NOD) go to question 8a Doyouhave dificult controlling your condition with medications or other physican-prescrbed therapies? ‘(Answer NO ifyou are not currently taking medications or other treatments) sO WO 8b. Doyoucommonly exhibit low resting blood pressure significant enough to cause dizziness, ight headedness, and/orfanting? vesQ) Nol) 8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysefedal sO w0Q) 9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event If the above condition(s) is/are present, answer questions 92-9 'fWOQ) g0 to question 10 2a Doyouhave dficulty controlling your condition with medications or other physican-prescrbed therapies? (Answer NOif you ate not currently taking medications or other treatments) yesQ noQ) $b. Doyouhave any impaltmentin walking or mobility? v0 n0Q) 9c. Have you experienced a stroke or impaimentin nerves or muscles in the past 6 months? v0 noQ) 10, — Doyou have any other medical condition not listed above or do you have two or more medical conditions? If you have other medical conditions, answer questions 104-10 tfNO() read the Page 4 recommendations 0a, Haveyou experienced abatout ented oot consclousnes asa result of ahead jy within the lst 12 yes) WoC) months ORhave you had a dagnosed concussion within the last 12 months? }05. _Doyou have a medical condition that isnot listed (such as eplepsy neurological conditions kidney problems!? Yes) NOC) (0c Doyoucurrentl live with two or more medical conditions? vesQ noQ) PLEASE LISTYOUR 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. cpigh9 2022 PAROS Coleboraon 3/4 ov-tn-20012022 PAR-Qt+t wt If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below: @® tis advised that you consult a palit exercise professional to help you develop asafeandeffective physical activity plan to meet your health needs. Youtgre encouraged te fart sowly and bud up cradualy 201060 minutes of ow to moderate intensity exercise, 355 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 Hyayare over the age of 45 yr and NOT accustomed to regular vigerous to maximal effort exercise consult qualified exercise professional before engaging in this intensity of exercise. @ If you 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 in afitness appraisal. You should complete the specaly designed online screening and exercise recommendations program - the ePARMed-X¢ at www.eparmedx.com and/or 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 health care practitioner, your physician a qualified 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-C+. 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 Xt. If in doubt after completing the questionnaire, consult your doctor prior to physical activity PARTICIPANT DECLARATION @ All persons who have completed the PAR-Ot please read and sign the declaration below. @ if you ae less than the legal age requited for consent or require the assent ofa 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 itis completed and becomes invalid if my condition changes. also acknowledge that the community/fitness center may retain a copy of this form for records. In these instances, it wll maintain the confidentiality of the same, complying with applicable law. NAME DATE SIGNATURE WITNESS. SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER Fotinore nformation, plaaseiconiact The PAI-Os was centedusng te eadencebasel AGREE proces 1)by he PANO eee oberon ded by Daren 8 Watton wth x Noman Gd Dy. sonia tl small: eparmedxegmallcom Janik, ad Dr DnaldMeKerle().Roducon of tis document as been made posse RE x onancin mi cattnnbatd tetany cat though ancl cntbutons rm the Ful Heath Agency of Canada andthe BCinisy Tethet nine Garachirmfcoteeeclcty | Hey Snes The ves exes hah donot ces represent the vewsofthe PublcHeath agency of aad athe Bis of Heath Sees. Neyer "ht itr Aor cD hgh Sean Ch nye ec enya veges AMES) 2 8, el kel Nebel nha dest aed aire Conan 2s 2 chen cai aL Coorg hs ead al hgh Fi rb NM Py citys Ci Moon WSN fe hcl Abts Ovesonate PARC Cand and open THR TEE cb 9 2022 PAROS Colboraton AY 4 ovan202