2022 PAR-Q+ ‘The Physical Activity Readiness Questionnaire for Everyone Oe ‘Theat benefits ofteguar pysal acy te dear mote people sould engage physica every day a wee. Tre eat benef of ea sale ee MOST peoples questonnare wi tel yOUwhether iscsi or yOU to Parting i EN ed eee tec batebcomingmore Seah ae ‘GENERAL HEALTH QUESTIONS Please ead the 7 questions below carefully and answer each one honesty: check YES or NO. _ [YES] NO +) Fas your doctor ever said thot you havea hear condition _JOR high blood pressure Oo 3) Do you fee pain in your chest ates, dung your dally activities of ving, OR when you do papacy : Oo 3) Do youllose balance because of dizziness OR have you lost consciousness in thelast !2 months? JT") Peat answer NO yout dazness wes asec th ver enting icudng dang vigorous exer 7) Have you ever been diagnosed with another chronic medical condition (other than heart disease} orhighblood pressure)? PLEASELIST CONDITIONS) HERE _ 5) Are you currently taking prescribed medications fora chronic medical condition? io PLEASE LIST CONDITION(S AND MEDICATIONS HERE: @ Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue {musele, ligament, or tendon) problem that could be made worse by becoming more physical Jf) [tive Howser NO yous sblemln she pati aes ot it our rent abit le phys ec PLEASELISTCONDONS) HERE: 7) Has your doctor ever seid that you should only do meclclly supervised physical activity? NINN AININ oq tyoasawerea NO tal ofthe estore ove Youre dure or PH aaaOY Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3. Srrbeconmng much mae pyle actve- stat Sel 7d BUS aadt © Folow Goss ype Atvy idan ory ge ps: fwonuhe in pub oe9785240015128. (Yours take prin sah afin appa iyunte rine ages ang NO accustomed to aula vigorous to masala esc consulta quafed ce © Sosa Rea a Le @ Hyouhove ny futher quetons contact quale xe poeson PARTICPANTECLARATION Fore eer equled consent rae th sent ofa cae provi, ou pte, guaran cate rode must Mosel ar eke rove jou patet, quan oat pro poate rad dentin il cen nce uma nana Lee anaT Ps trae 2 month om beans completes snd comes mvs my cngtion changes setantaus contr ay ean a copy FN os ear these nance ll Mal CeeRiy che seme complies wih appa bm. Soe peal NAME BU one_Jewery 04,2045 a - ness Zeviog, — Algving sicuarune 0 ARENT GUARBDACARE PROWDER <2 @ ifyou answered YES to one or more ofthe questions above, COMPLETE PAGES 2 AND 3. ‘a deiey bearing ore active Seamer acct acre renee arses Tpuaaree su ent esd ome eter te sooth andor tao you doar oa quaied eerie Sean RAP NTC 4Ifyou answered NO to all of the FOLLOW-UP questions 2-3) about ir medical condition, Frenne NO ony Leap te PANTIGPANT DECLARATION below Se aac andy to become ror cece notsnd op you develo ase and fete Pt a a en eae aaa soy gartslony nd bul p acu ota crntesf [ow toredett end exe © Your oncouaae es sete man Renae execs 3 Osage se you oud into accumulate 150 mines ot mare of models cal atv per mek Scare cranenneo4sy ng WOT accused org gorousto mn fot err Ons? ie AE ta MO re oh (ausiied exerase professional @ liyousnswered VES to one oF mare ofthe follow-up questions abo\: your ‘medical condition? To aaa ve raerrfornaton tere beaming ore yc ace orenaaggin fies apraal You hal Sn Ten eg onne seerin and exerese commendations progam the aPaRed Xe at arr aa a jena te wok hevugh the ePamed Xe af furernermatn, ‘As Delay becoming more active Hf: “YYouhave tempore ness suchasacldofever ts besttowal unity fe bei vtouare pregrant-takto your heath care prettoner you physician a auafied exis pofessionah ae ediatt ie cPanmed Xe at wweparmedscom ecbesaming ore pryseay sive. f_ Toutesin changes talk toyour doctor or quaifed execs professional before continuing with any physical etivty program uae enenuraged to potouapy te PAR-O+-Youmust use the ane questionaire and NO changes fe permtted SNe rca Coluboton artre organizalos, andthe ages assume no tabiy Gr peons The authors he PAG oy anole make wae ofthe PAR Qs oF ePARd- Ht in doubt after completing the questonnae, pesTeyour goctor prior to physical activity. PARTICIPANT DECLARATION rT perme who have completed the PARQ pease read andslgn the deaaion Below iryauaresthan he legs age vequredor consent reque the ssn of cae prover your paren ladan arte ‘rondermuskaso ign thistorm your paren ‘ane undersigned have rod understood tomy fll satisfaction and completed this questionnaire, acknowledge 1 he a cnt cearance fs vl for armaximum of 12 months from the date ts completed and becomes that this Dye tioncranges labo acknowledge tat the communiyfsness center may retain 0 copy ofthis eval my cone ese stances, wl alntan the confidentiality ofthe same, complying with applicable we ome_ OMY 09,2025 ‘SIGNATURE. wnrvess_ER/ER _AQUEO _ SIGNATURE OF eg For more information, please contact = Se srewapurmedco Cutouon cht Oconto wh Roman Wen eee ‘retina th rage anne = actararcmgenmicice_, | humparat cao oe Anca ee siseeresensnope crete, | Samson neve ersinomnds nny rot Review be ‘btca agent ads ana Nese —, nero ate te pet inten ing se nc te i stn etree S828 mena note cbse 7EStonce sat myname ed 2o nn entero herconanpne S D eae 22? caitenon 4/4 aa