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2021 PAR-Q+ General Health Questions
Basic Accounting (BSA101)
Notre Dame of Midsayap College
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The Physical Activity Readiness Questionnaire for Everyone
The health bene ts of regular physical activity are á clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a quali ed exercise professional before becoming á more physically active.
Please read the 7 questions below carefully and answer each one honestly: check YES or NO. YES NO
1) Has your doctor ever said that you have a heart condition high blood pressure? OR
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 ch ?ronic medical condition
7) Has your doctor ever said that you should only do medically supervised physical activity?
2) Do you feel pain in your chest at rest, during your daily activities of living, when you do OR
physical activity?
3) Do you lose balance because of dizziness have yOR ou lost consciousness in the last 12 months?
Please answer if your dizziness was associatNO ed with over-breathing (including during vigorous exercise).
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 if you had a problem in the past, buNO t it does not limit your current ability to be physically active.
PLEASE LIST CONDITION(S) HERE:
GENERAL HEALTH QUESTIONS
If you answered NO to all of the questions above, you are cleared for physical activity.
Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.
If you answered YES to one or more of the questions above, COMPLETE PAGES 2 AND 3.
####### Delay becoming more active if:
You have a temporary illness such as a cold or fever; it is best to wait until you feel better. You are pregnant - talk to your health care practitioner, your physician, a quali ed exercise professioá nal, and/or complete the ePARmed-X+ at eparmedx before becoming more physically active.
Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a quali ed exercise á professional before continuing with any physical activity program.
Copyright © 2021 PAR-Q+ Collaboration1 / 4 01-11-
PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Start becoming much more physically active – start slowly and build up gradually.
Follow Physical Activity Guidelines for your age (who/publications/i/item/9789240015128).Global
You may take part in a health and tness appraisal. á
If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal e ort exercise, consâ ult a quali ed exercise á professional before engaging in this intensity of exercise.
If you have any further questions, contact a quali eád exercise professional.
PARTICIPANT DECLARATION If you 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.
I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I 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. I also acknowledge that the community/ tness center may retá ain a copy of this form for its records. In these instances, it will maintain the con dentiality of the same, complying with applicablá e law.
####### NAME ____________________________________________________
####### SIGNATURE ________________________________________________
####### SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER ____________________________________________________________
####### WITNESS _____________________________________
####### DATE __________________________
2021 PAR-Q+
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####### 1. Do you have Arthritis, Osteoporosis, or Back Pro blems?
1a. Do you have di culty controlling your condition á with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
1b. Do you have joint problems causing pain, a rece nt fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?
1c. Have you had steroid injections or taken steroi d tablets regularly for more than 3 months?
####### If the above condition(s) is/are present, answer questions 1a-1c If NO go to question 2
####### 2. Do you currently have Cancer of any kind?
####### If the above condition(s) is/are present, answer questions 2a-2b
####### 3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure,
####### Diagnosed Abnormality of Heart Rhythm
####### If the above condition(s) is/are present, answer questions 3a-3d
####### If the above condition(s) is/are present, answer questions 5a-5e
####### 5. Do you have any Metabolic Conditions? This inclu des Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes
####### If NO go to question 3
####### If NO go to question 4
####### If NO go to question 6
####### 4. Do you currently have High Blood Pressure?
####### If the above condition(s) is/are present, answer questions 4a-4b
4a. Do you have di culty controlling your condition á with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)
####### If NO go to question 5
2a. Does your cancer diagnosis include any of the f ollowing types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?
2b. Are you currently receiving cancer therapy (suc h as chemotheraphy or radiotherapy)?
3a. Do you have di culty controlling your condition á with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
3b. Do you have an irregular heart beat that requir es medical management? (e., atrial brillation, premature ventricular coâ ntraction)
3c. Do you have chronic heart failure?
3d. Do you have diagnosed coronary artery (cardiova scular) disease and have not participated in regular physical activity in the last 2 months?
5a. Do you often have di culty controlling your bloo á d sugar levels with foods, medications, or other physician- prescribed therapies?
5b. Do you often su er from signs and symptoms of lo ã w blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, di culty speaking, weakness, or slá eepiness.
5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications a ecting your eyes, kidneys, ã OR the sensation in your toes and feet?
5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?
5e. Are you planning to engage in what for you is u nusually high (or vigorous) intensity exercise in the near future?
2021 PAR-Q+
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S)
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Copyright © 2021 PAR-Q+ Collaboration2 / 4 01-11-
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2021 PAR-Q+
PARTICIPANT DECLARATION
####### NAME ____________________________________________________
####### SIGNATURE ________________________________________________
####### SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER ____________________________________________________________________
####### DATE _________________________________________
####### WITNESS ______________________________________
Copyright © 2021 PAR-Q+ Collaboration4/ 4
####### For more information, please contact
Key References
eparmedx Email: eparmedx@gmail
- Jamnik VK, Warburton DER, Makarski J, McKenzie DC, Shephard RJ, Stone J, and Gledhill N. Enhancing the eáectiveness of clearance for physical activity participation; background and overall process. APNM 36(S1):S3-S13, 2011.
- Warburton DER, Gledhill N, Jamnik VK, Bredin SSD, McKenzie DC, Stone J, Charlesworth S, and Shephard RJ. Evidence-based risk assessment and recommendations for physical activity clearance; Consensus Document. APNM 36(S1):S266-s298, 2011.
- Chisholm DM, Collis ML, Kulak LL, Davenport W, and Gruber N. Physical activity readiness. British Columbia Medical Journal. 1975;17:375-378.
- Thomas S, Reading J, and Shephard RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Canadian Journal of Sport Science 1992;17:4 338-345.
Citation for PAR-Q+ Warburton DER, Jamnik VK, Bredin SSD, and Gledhill N on behalf of the PAR-Q+ Collaboration. The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and Electronic Physical Activity Readiness Medical Examination (ePARmed-X+). Health & Fitness Journal of Canada 4(2):3-23, 2011.
If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition,
you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:
If you answered YESto one or more of the follow-up questions about your medical condition:
You should seek further information before becoming more physically active or engaging in a tness apprâ aisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at eparmedx and/or visit a quali ed exercise professional to work throuâ gh the ePARmed-X+ and for further information.
####### It is advised that you consult a quali ed exercise pâ rofessional to help you develop a safe and e ective á physical
####### activity plan to meet your health needs.
####### You are 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.
####### As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.
####### If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal eáort exercise, consult a
####### quali ed exercise professional before engaging in thâ is intensity of exercise.
####### All persons who have completed the PAR-Q+ please read and sign the declaration below.
####### If you 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.
####### Delay becoming more active if:
####### You have a temporary illness such as a cold or fever; it is best to wait until you feel better.
####### You are pregnant - talk to your health care practitioner, your physician, a quali ed exercise professioâ nal,
####### and/or complete the ePARmed-X+ at eparmedx before becoming more physically active.
####### Your health changes - talk to your doctor or qualiâed exercise professional before continuing with any physical
####### activity program.
####### You are encouraged to photocopy the PAR-Q+. 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-Q+ or ePARmed-X+. If in doubt after completing the questionnaire,
####### consult your doctor prior to physical activity.
I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I 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. I also acknowledge that the community/ tness center may retain a copy of this â
form for records. In these instances, it will maintain the con dentiality of the same, complying with applicabâ le law.
The PAR-Q+ was created using the evidence-based AGREE process (1) by the PAR-Q+ Collaboration chaired by Dr. Darren E. R. Warburton with Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Donald C. McKenzie (2). Production of this document has been made possible through nancial contributions from the Public Healtâ h Agency of Canada and the BC Ministry of Health Services. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada or the BC Ministry of Health Services.
01-11-
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2021 PAR-Q+ General Health Questions
Course: Basic Accounting (BSA101)
University: Notre Dame of Midsayap College
