Schedule an Assessment

Date / Time

Date

Time

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by doctor? *

Yes
No

2. Do you feel pain in your chest when you do exercise? *

Yes
No

3. In the past month, have you had chest pain when you were not doing physical activity? *

Yes
No

4. Do you loose your balance because of dizziness or do you ever loose consciousness? *

Yes
No

5. Do you have a bone or joint problem (for example, back, knee ankle or hip) that could be made worse by a change in your physical activity? *

Yes
No

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes
No

7. Do you have another reason you should NOT do physical activity? *

Yes
No

Disclaimer

IF YOU ANSWERED YES TO ONE OR MORE QUESTIONS ABOVE Talk to your physician by phone or in person BEFORE you start any new physical activity and before starting any fitness evaluation. Tell you're Dr. about the par-q and which questions you answered YES.

You may be able to do any physical activity you like, just do it slowly, progressively and gradually. Speak to your doctor about the kinds of activities you'd like to participate in moving forward.
Find out specifically what is safe for you to do.

If you answered NO to all questions:

1. Start becoming more Physically active--Begin slowly and build up gradually!
2. Contact us for a Health & Medical Appraisal
3. This is the best way to determine your basic fitness to make a plan!
DELAY BECOMING MUCH MORE ACTIVE:
1. IF YOUR NOT FEELING WELL BECAUSE OF TEMPORARY ILLNESS...WAIT UNTIL YOU ARE BETTER
2. if you are or maybe pregnant, discuss starting a program before changing your physical activity.
PLEASE NOTE:
As your health changes, and your YES becomes a NO, Tell your fitness/ Health team. Check in to see if you can modify your plan!

I Fully Understand

THIS PHYSICAL ACTIVITY CLEARANCE IS ONLY VALID FOR 1 YEAR FROM THE DATE ABOVE.

IT BECOMES INVALID IF CONDITIONS CHANGE SO THAT YOU WOULD ANSWER YES TO ANY OF THE TOP 7 QUESTIONS.

I HAVE READ, UNDERSTOOD AND COMPLETED THIS QUESTIONAIRE HONESTLY.

BY SUBMITTING THIS FORM I AM ATTESTING THAT ALL OF THE ABOVE ARE TRUE

Assessment

Disclaimer

I Fully Understand

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