2023 PAR-Q+ The Physical Activity Readiness Questionnaire for Everyone The health benefits of regular physical activity ae clear more people should engage in physical actvty every day ofthe week. Participating in physical activity ver safe for MOST people. This questionnaiewilltell you whether s necessary for you to seek further advice from your doctor OR qualifed exercise professional before becoming more physically active GENERAL HEALTH QUESTIONS Please read the 7 questions below ly and answer each one honesth 1) Has your doctor ever said that you have a heart condition Q OR high blood pressure)? 2) Do you feel pain in your chest at rest, during your daily activities of living, 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 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 ifyou hada problem in the past, butt dees not limit your current ability to be physically activ, PLEASE LIST CONDITION(S) HERE: 7) Has your doctor ever said that you should only do medically supervised physical activity? oh you answered NO toall ofthe questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3. Start becoming much more physically active start slowly and build up gradually. © Follow Global Physical Activity Guidelines for your age (https://wnw.who int/publications/v/itenn/9789240015128) @ You may take part in a health and fitness appraisal, If youare over the age of 4 yr ane NOT accustomed to regular vigorous to maximal effort exercise, consulta qualified exercise © fessional before engaging in this ntensty ofexerese. " © fyounave any further questions, contact qualified exercise professional PARTICIPANT DECLARATION Ifyou ae less than the legal age required for consent or requite the assent ofa cate provider, your parent, quardian or cae provider must alzosign thi form, |, the undersigned, have read, understood to my full satisfaction andl completed this questionnaire. | acknowledge that this physical activity clearance is valid for a maximum of 12 months rom the date itis completed and Becomes invalid if my condition changes, | also, acknowledge that the community/itness center may retain a copy of this form for its records. In these instances t wil maintain the Confidentiality ofthe same, complying with applicable law. NAME DATE SIGNATURE WITNESS. ‘SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER @ If you answered YES to one or more of the questions above, COMPLETE PAGES 2 AND 3. ‘Ax Delay becoming more active if: Youhavea temporary lines such asa cold or fever itis best to wait until you fel better. Youre pregnant talk to your health care practitioner, your physician, a qualified exercise professional andor complete the BARI aSaS! won epatmedncom before Becoming more physically adtve c : Your health changes - answer the questions on Pages 2 and 3 ofthis document and/or talk to your doctor ora qualified exercise Brofessinal before continuing with any physical ava program. 2 : Copyngheo ans PARC caoboaton | /2023 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 HNO) goto question 2 Doyou have sifcuty controling your condion with mecleatinsor other physkiamprecbed therapies? ves) wo (Answer NO if you are not currently taking medications or other treatments) OO 1b. Do you have joint problems causing pain, a recent fracture o fracture caused by osteoporosis or cancer, displaced vertebra (eg, spondylolisthess), and/or spondylolysi/pars defect (a crackin the bony ing an the YES) NOC) backof the spinal column? 1e___ Have you had steroid injections or taken steroid tablets regularly for more than 2 months? ves) Nol 2 Doyou currently have Cancer of any kind? Ifthe above condition(s) is/are present, answer questions 2a-2b NOD) go to question 3 22, Does your cancer diagnosis include any ofthe following types: ung/bronchogeni, multiple myeloma (cancer of plasma cal) head, andlor neck? 0 OQ 2%, __Areyou currently receiving cancer therapy (such as chemotherapy or radiotherapy)? Yes) wo) 3. Doyou havea Heart or Cardiovascular Condition? This indudes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm Ifthe above condition(s) is/are present, answer questions 3a-3d 'fNOD) go to question 4 2a, Doyouhave difficulty controling your condition with medications or other physician prescribed therapies? {irawer NO you are not current taking mesdeations or other testments) eo) 3b. Doyou have anirregular heartbeat that requires medical management? (e.g, arial frilation, premature venticular contraction) ayaa 3<__Doyouhave chronic hear faire? ves) NOD) 3d, Doyou have diagnosed corgnary artery (cardiovascular disease and have not participated in regular physical Salty nthelast2 months? eee vs 100) 4. Doyoucurrently have High Blood Pressure? Ifthe above condition(s) is/are present, answer questions 4a-4b ifNOD) goto question S 42, Doyou havedificulty contraling your condition with medications or other physcian-pescribed therapies? Canter NOI you aenot current taking mesicatons or lher treatments) 0 10 a, Do you havea esting bloodpressure equal too eater than 160/90 mig with or without medication? (atl WBSiyou So nexangn your esa blood presote vs) wo Doyyou have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes Ifthe above condition(s) is/are present, answer questions 5a-Se NO () go to question 6 5a, Doyouoften have iffiulty controling your blood sugar levels with foods, medications, or other physician- YES) no} prescribed therapies? 0 wO 3e.___Doyou often sue from signs and sympioms of low blood sugar (hypoglycemia) folowing exercise and/or uring activities of dally living? Signs of hypoglycemia may include srakiness nervousness, unusual rrtabilty, yes) No| Sbnottnal sweating dssnessorighchendedress mental Confusion ety speaking weakness orsieepiness. "O) 8OO Se Doyouhave any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications acting your eyes ke, OR the sensation in your toes and fet? sO WO 5d, Doyouhave other metabolic conditions (auch as current pregnancy-elated diabetes, chronic Kidney disease, or lve problems)? sO WO Se. re you planning to engage in what for you is unusually high (or vigorous) intensity exercise inthe near future? Yes) NOC) copyight 2023 PAR Calaoraton 2 / 1-11-20222023 PAR-Q+ 6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome. ifthe above concitions is/are present, answer questions 62-65 1fNOD) go to question 7 62. Doyouhaye dificult controling your condltion with medication or other physican-pescibed therapies? ves) no (Answer NO if you are not currently taking medications or other treatments) ‘8 weO 4b. Doyouhave Down Syndrome AND back problems affecting nerves or muscles? vs) oO) 1. Doyou havea Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure ifthe above conditions is/are present, answer questions 72-7 IND) go to questions 7a. Doyou have aifcuty cotroling your condition with medications or other physician prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) vesQ no 7b. fas your doctor ever sid your blood oxygen levels low at est or during exercise and/or that you require supplemental onygen therapy? ves) NoQ) Je. asthmatic do you curenty have symptoms of chest uightness wheeting laboured breathing consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week? vesD noD 7a. Was your doctor ever aid you have high blood pressure inthe blood vessels of your lungs? v0) oD) 8. Doyouhavea Spinal Cord Injury? This includes Tetraplegia and Paraplegia Ifthe above condition(s) is/are present, answer questions 8a-8¢ 1fNOD) go to question 9 8. Doyouhaye dificult controling your condltion with medications or other physlcan prescribed theraples? (Answer NQ if you are not currently taking medications or other treatments) ves) so) Do you commonly exhibit ow resting blood pressure sgnicant enough to cause alzrness ightheadedness ‘ ler fainting ane low resting Blood ps eee ae » vesQ) Nol) 3 flasyour physician indicated that you exhibit sudden bouts of igh blood pressure known as Autonomic Dysteheray Ue a ves) sD) 9% Haveyou had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event ifthe above concitions) is/are present, answer questions 92-9c NOC] go to question 10 92. Doyouhavedificuly controling your condition with medication or other physician prescribed therapies? Uinrswer NO you are not current taking medications or other estments) vs) sO) Sb. Do you have any mpakmentin walking or mobility? 0) oD) 3c ave you experienced a stroke or impairment In nerves ormuscles inthe past months? YO) sO) 10, Do you have any other medical condition not listed above or do you have two or more medical conditions? Ifyou have other medical conditions, answer questions 10a-10c 1fNO CD) read the Page 4 recommendations 10a. Have you experience ablackout fainted, o lost consciousness as. result of ahead injury within the lst 12 months ORhave you had a diagnosed concussion within the last 12 months? vesQ NoO) 10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems}? YeS() NOC) 0c. Doyou currenty live with two or more medical conditions? vesQ) nol) PLEASE LIST YOUR | NL TIONS [AND ANY RELATED MEDICATIONS H GO to Page 4 for recommendations about your current medical condition(s) and sign the PARTICIPANT DECLARATION. copyight 2023 PARA Calloraton 3/4 1-11-20222023 PAR-Q+ (gH ifyou answered NO to all ofthe FOLLOW-UP questions (pgs.2-3) about your medical condition, youare ready to become more physically active - sign’ ICIPANT 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. © _Youare encouraged to start slowly and build up gradually -20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises. @ Asyou progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week I you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a 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 ina fitness appraisal. You should complete the specially 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: hf Youhave a temporary illness such as.a cold or fever; itis best to wait until you feel better. of Youare pregnant. tak to your health care practioner your physician, qualified exercise professional, and/or complete the ePARmed:X+ at wwrw.eparmedx.com before becoming more physically active. oP Yeurhealth changes tak to your doctor or qualified exercise professional before continuing with any physical activity program. © You are encouraged to photocopy the PAR-O+. 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-O+ or ePARmed-X+. Ifin doubt after completing the questionnaire, consult your doctor prior to physical activity 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 if my 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 TTR scat ng th scene based AGREE proce by a RT cematrnwapermeds.com Catabraton hated y Dx Daven ER Wan wth Dr Noman lel Veronica . mail: eparmedx@gmail.com Jami nd DonadC Metenle 2 odscon of ths docmenthas been made posse Seta ins cent one temas altos trough fnancia contibutions rom the Public Health Agency of Canada ond the BC Minty Bev ha erence an of Health Senaces. The views expeered herein do natnecestary represen the views ofthe Public Health Agency of Cana c the BC Minty of Health Services, eyes Th rok stark eee Sah Sore oe Ghee stone hace paliy pesto cond ce ANT 20 “omfg dha fl Reon ot Pcl Ay anes Gascon Can ep Sc 217 ES, copyight 2023 PAR Clloraton 4/4 1-11-2022