NAME: ___________________________________

YR & SECTION: ___________________________

DATE: ___________________________________

Activity: Personal Health History Questionnaire

Directions: While physical fitness tests and participation are relatively safe for most healthy
people, the cardiovascular system's reaction to increased physical activity cannot be predicted.
Thus, you must provide honest answers to this questionnaire. Physical fitness activity can be ill-
advised under some of the following conditions given below. If any of the conditions apply, consult
a doctor before taking part in a physical fitness test and obtain a doctor's medical certification.
Also, immediately report any related physical fitness activity issues that you may experience
during the physical fitness test and participation throughout the workout.

Your Medical History Please indicate if YOU have a history of the following:

• Alcohol Abuse • Osteoporosis • Asthma

• Anemia • Migraines • Bladder Problems
• Anxiety Disorder • Reflux/GERD • Blood Transfusion
• Arthritis • Rectal Cancer • Cervical Cancer
• Autoimmune Problems • Sexually Transmitted • Diabetes
• Birth Defects Disease • Prostate Cancer
• Bleeding Disease • Stroke/CVA of the Brain • Seizures
• Blood Clots Skin Cancer • Severe Allergy
• Bowel Disease • Ulcer • Thyroid Problems *
• Breast Cancer • Suicide Attempt • Other Diseases or
• Colon Cancer • Visual Impairment Illnesses
• Depression • NONE of the Above
• COVID-19 • Anesthetic Complication

Your Family Medical History Please indicate if YOUR FAMILY has a history of the following: (ONLY
include parents, grandparents, siblings, and children)

• Alcohol Abuse • heart disease • NONE of the Above

• Anemia • Kidney Disease
• Arthritis • High Blood Pressure
• Asthma • Lung/Respiratory Disease
• Bleeding Disease • Leukemia
• Breast Cancer • Migraines
• COVID-19 • Other Cancer
• Diabetes • Seizures/Convulsions -
• Depression Stroke/CVA of the Brain
• High Cholesterol • Severe Allergy
• Anesthetic Complication • Osteoporosis
• Bladder Problems • Rectal Cancer
• Colon Cancer • Thyroid Problems

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers.
DRUG _______________________________________________________________
DOSE/FREQUENCY ____________________________________________________

DRUG _______________________________________________________________
DOSE/FREQUENCY ____________________________________________________

 I take no medications, vitamins, herbals, or any other over-the-counter preparations

 Allergies
• I have no known drug • Heart Attack • Lung Cancer
allergies • Hepatitis A • NONE of the Above
• Hearing Impairment - • High Blood Pressure • I have no known drug
Heart Pain/Angina • Hives allergies
• Hepatitis C • Liver Disease - Mental • Hearing Impairment -
• HIV Illness Heart Pain/Angina
• Liver Cancer • Heart Disease • Hepatitis C
• Lung/Respiratory Disease • Hepatitis B • HIV
• Growth/Development • High Cholesterol • Liver Cancer
Disorder • Kidney Disease • Lung/Respiratory Disease

Surgeries
YEAR _________________________________________________________________
REASON ______________________________________________________________
HOSPITAL _____________________________________________________________

YEAR _________________________________________________________________
REASON ______________________________________________________________
HOSPITAL _____________________________________________________________

 I had no surgeries

Other hospitalization
YEAR _________________________________________________________________
REASON ______________________________________________________________
HOSPITAL _____________________________________________________________

YEAR _________________________________________________________________
REASON ______________________________________________________________
HOSPITAL _____________________________________________________________

 I have never been hospitalized in the last 12 months

I hereby provide the aforesaid personal information granted that it will be used for legal
purposes only and treated with the utmost sensitivity and confidentiality as specified by the
Republic Act 10173 (Data Privacy Act of 2012).

_______________________________________
Signature over Printed Name of Students
 Test: Physical Activity Readiness Questionnaire (PAR-Q)

Directions: Physical activity offers numerous health benefits more people should engage in physical
activity every day. For the vast majority of people, physical activity is generally safe. This questionnaire
will assess whether you need to get extra advice from your doctor OR a qualified exercise professional
before increasing your physical activity level. The Physical Activity Readiness Questionnaire (PAR-Q)
is a seven-question yes/no questionnaire that is quick and simple to answer. Please read the seven
questions carefully and answer each one honestly by writing YES or NO in the blank space provided
below. Your responses to these questions can determine whether you are ready to start an exercise
program or increase the intensity of your present program.

Question
YES NO

1. Has your doctor ever told you that you have a heart condition and that you should only engage in
physical activity that has been prescribed by a doctor?
2. Do you get chest pain when engaging in physical activity?
3. Have you had chest pain while not engaging in physical exercise in the last month?
4. Do you ever lose your balance or consciousness as a result of dizziness?
5. Do you have a bone or joint condition that could be aggravated by a change in your physical
activity?
6. Is your doctor currently providing you with medication to treat your high blood pressure or heart
condition?
7. Do you have any other reasons why you should avoid physical activity?

I, the undersigned, have read, fully comprehended, and completed this questionnaire. I
understand that this physical activity clearance is only valid for 12 months from the date it is completed
and will become invalid if my condition changes. I also understand that my PATHFIT 2 instructor may
keep a copy of this form for their records. In this case, it will maintain the confidentiality of the
information by applicable law.

_______________________________________
Signature over Printed Name of Students