Par-Q

yes	no
		1. Has your doctor ever said that you have a heart condition and recommended only medically approved physically activity?
		2. Do you have chest pain brought on by physical activity?
		3. Have you developed chest pain at rest in the past month?
		4. Do you lose conciousness or lose your balance as a result of dizziness?
		5. Do you have a bone or joint problem that could be aggravated by physical activity?
		6. Is your doctor currently prescribing medication for your blood pressure or heart condition? (e.g.:diuretics or water pills)
		7. Are you aware, through your own experience or a doctor's advice, of any other reason against your exercising without medical approval?

Notes:

1. This questionnaire applies only to those 15 to 69 years of age.
2. If you have a temporary illness, such as fever, or are not feeling well at this time, you may wish to postpone the proposed activity.
3. If you are pregnant, you are advised to consult with your physician before exercising.
4. If there are any changes in your status relative to the above questions, please bring this information to the immediate attention of your fitness professional.

Source: This screening tool has been derived from many sources, primarily the Physical Activity Readiness Questionnaire, British Columbia Ministry of Health Department of National Health and Welfare, Canada, revised 1992.