Physical Activity Readiness Questionnaire (PAR-Q)

The PAR-Q is a simple self-screening tool to determine the safety or possible risk of exercising for an individual based on their health history, current symptoms and risk factors. It also can help us to design an ideal exercise prescription for you based on these results.

All the questions are designed to help uncover any potential health risks associated with exercise. Please read it through and fill out to the best of your knowledge.

It takes approximately 3-10 minutes to complete the form.

- Step 1 of 8

Our records indicate that you have not yet completed the health questionnaire.

It is necessary to complete this questionnaire to proceed.

Begin

Declaration *

• I'm over 18
• I'm a guardian of someone who is under 18

Next

Your Details

Guardian's Name *

First

Last

Guardian's Date of Brith *

Declaration *

• I confirm that I am the responsible guardian of the child who is under 18 years of age and all the information I provide about the child in this document is correct.

From this point on, please provide information about the child. At the very last page, use your own name in the signature field before submitting the form.

Child's Details

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Phone

Next

Emergency Contact

Emergency Contact Name *

Relationship

Emergency Contact Phone Number *

Emergency Contact Email Address

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General Health and Medical History

How would you describe your general health and fitness?

Have you ever done any structured exercise? If yes please specify (weight training, yoga, HIIT classes, running, etc)

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General Health and Medical History

Do you ever get unusually short of breath with very light exertion? *

• No
• Yes

Do you ever have pain, pressure, heaviness or tightness in the chest area? *

• No
• Yes

Do you ever experience palpitations or irregular heartbeats? *

• No
• Yes

Do you regularly have unexplained pain in the abdomen, shoulders or arm? *

• No
• Yes

Do you ever have severe dizzy spells or episodes of fainting? *

• No
• Yes

Do you regularly get lower leg pain during walking that is relieved by rest? *

• No
• Yes

Are you currently pregnant or have you given birth in the last 6 months? *

• No
• Yes

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General Health and Medical History

Have you had a major illness or injury in the last 5 years? *

• No
• Yes (please specify below)

Details *

Are you receiving treatment for any diagnosed medical condition? *

• No
• Yes (please specify below)

Details *

Are you taking any prescription medication? *

• No
• Yes (please specify below)

Details *

Do you have any aches, pains or problem areas? (Bone, joint, muscular etc) *

• No
• Yes (please specify below)

Details *

Are any of these injuries aggravated by exercise? *

• No
• Yes (please specify below)

Details *

Are you currently receiving treatment for any structural problem? *

• No
• Yes (please specify below)

Details *

Is there any other health problems you suffer from which you have not already mentioned? *

• No
• Yes (please specify below)

Details *

Do you have notes or letters from doctors, physio etc.? *

• No
• Yes (please upload them below)

Upload files *

Click or drag files to this area to upload. You can upload up to 10 files.

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Declaration

Declaration *

• If you answered YES to one or more of the follow-up questions about your medical condition, you should seek further information from your personal GP before becoming more physically active or engaging in a fitness appraisal. This PAR-Q becomes invalid should your condition change.

Declaration *

• I have read and fully understand this questionnaire and confirm that, to the best of my knowledge, the answers I have given are accurate and correct.

Declaration *

• I acknowledge that any suggestion from Adam Kalotai regarding exercise, healthcare and nutrition are neither diagnostic nor prescriptive.

Declaration *

• I agree to notify Adam Kalotai of any future changes to the above answers before continuing to exercise.

Declaration *

• By submitting this form I acknowledge that I, the undersigned, have read, understood and completed this questionnaire to my full satisfaction and this physical activity clearance is valid. I confirm I am able to exercise and do not hold Adam Kalotai responsible for anything that has not be declared on this form.

Signature (type your full name) *

Guardian's Signature (type your full name) *

Email

Submit