1CY2023_2023_PL5TD5

PNPHS FORM 2020-01

Republic of the Philippines

National Police Commission
PHILIPPINE NATIONAL POLICE
HEALTH SERVICE
Camp PBGen Rafael T Crame, Quezon City

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR Q)

For Physical Agility Test (PAT)
DATE: _______________________

LAST NAME FIRST NAME MIDDLE NAME AGE SEX CIVIL STATUS

VERANO JOHN JAYCOH SAVILLA

NEXT OF KIN (NAME, RELATIONSHIP, ADDRESS, CONTACT NO.) CONTACT NUMBER

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE. This questionnaire is being given to the participant before any physical
activity or exercise. This may be used for legal and/or administrative purposes.
To be accomplished by the participant: Please read carefully and answer each one honestly: Check YES or NO.
YES NO
‫ﭪ‬ ‫ﭪ‬ 1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommend by a doctor?
‫ﭪ‬ ‫ﭪ‬ 2. Do you feel pain in your chest when you do physical activity?
‫ﭪ‬ ‫ﭪ‬ 3. In the past month, have you had chest pain even when you are not doing physical activity?
‫ﭪ‬ ‫ﭪ‬ 4. Do you experience shortness of breath or difficulty in breathing when doing physical activity?
‫ﭪ‬ ‫ﭪ‬ 5. Has any doctor ever said you have diabetes or increased blood sugar?
‫ﭪ‬ ‫ﭪ‬ 6. Have you had blood pressure over 140/90?
‫ﭪ‬ ‫ﭪ‬ 7. Do you lose balance because of dizziness or do you ever lose consciousness?
‫ﭪ‬ ‫ﭪ‬ 8. Do you have a bone or joint problem? For example knee or hip that could be made worse by a change in physical activity?
‫ﭪ‬ ‫ﭪ‬ 9. Have you had fever, cough, colds or even vehicular accident in the past week that required bed rest?
‫ﭪ‬ ‫ﭪ‬ 10. Do you know any other reason why you should not do any physical activity?

“I have read, understood and accurately completed this questionnaire. I attest that the above information are true and correct to
the best of my knowledge. I confirm that I am voluntary engaging in this physical agility test and my participation involves a risk
of injury. I understand that failure to disclose any pertinent medical information puts me at risk and can be held against me in my
PNP application”

___________________________________________ DATE:_____________________
Name/Signature of Applicant

FOR MEDICAL STAFF

BP 2nd BP 3rd BP ECG RESULT: Encircle:

GO
PR 2nd PR 3rd PR
NO GO
___________________________________
Signature over printed name of Medical Officer