PAR-Q+PAR-Q+ Admin Use Only PAR-Q+ The health benefits of regular physical activity are 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 qualified exercise professional before becoming more physically active. This form is not to be considered a medical document or medical advice. Always consult your doctor before starting an exercise program. 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 financial contributions from the Public Health 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. Date * Membership ID Name * Name First First Last LastAddress * Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Phone * Email * Age * HEALTH HISTORY FORM1. Has your doctor ever said that you have a heart condition or high blood pressure? * Yes No2. Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? * Yes No3. 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). * Yes No4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure? * Yes No 4a. If YES to question above, Please list the conditions here: * 5. Are you currently taking prescribed medications for a chronic medical condition? * Yes No 5a. If YES to question above, Please list your the condition(s) and medication(s) 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 if you had a problem in the past, but it does not limit your current ability to be physically active.) * Yes No 6a. If YES to question above, Please list the conditions here: * 7. Has your doctor ever said that you should only do medically supervised physical activity? * Yes No 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. Start becoming much more physically active - start slowly and build up gradually. Follow Global Physical Activity Guidelines for your age (https://www.who.int/publications/i/item/9789240015128). You may take part in a health and fitness appraisal. If you are over t he 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 have any further questions, contact a qualified exercise professional. PARTICIPANT SIGNATUREIf 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/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. QUESTIONS ABOUT MEDICAL CONDITIONSIf you answered YES to one or more of the first questions, please answer these questions.1. Do you have Arthritis, Osteoporosis, or Back Problems? * Yes No1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) * Yes No1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)? * Yes No1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months? * Yes No2. Do you currently have Cancer of any kind? * Yes No2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck? * Yes No2b. Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)? * Yes No3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm * Yes No3a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) * Yes No3b. Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction) * Yes No3c. Do you have chronic heart failure? * Yes No3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months? * Yes No4. Do you currently have High Blood Pressure? * Yes No4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) * Yes No4b. 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) * Yes No5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes * Yes No5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies? * Yes No5b. Do you often suffer from signs and symptoms of low 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, difficulty speaking, weakness, or sleepiness. * Yes No5c. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)? * Yes No5d. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future? * Yes No6. 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 * Yes No6a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) * Yes No6b. Do you have Down Syndrome AND back problems affecting nerves or muscles? * Yes No7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure * Yes No7a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) * Yes No7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy? * Yes No7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough YES O NOD (more than 2 days/week), or have you used your rescue medication more than twice in the last week? * Yes No7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs? * Yes No8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia. * Yes No8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) * Yes No8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting? * Yes No9. Have you had a Stroke? This includes Transient lschemic Attack (TIA) or Cerebrovascular Event. * Yes No9a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) * Yes No9b. Do you have any impairment in walking or mobility? * Yes No9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months? * Yes No10. Do you have any other medical condition not listed above or do you have two or more medical conditions? * Yes No10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months? * Yes No10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)? * Yes No10c. Do you currently live with two or more medical conditions? * Yes No If you answered NO to al I of the FOLLOW-UP questions about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below: It is advised that you consult a qualified exercise professional to help you develop a safe and effective 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 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 in a fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information. 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 qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active. Your health changes - talk to your doctor or qualified exercise professional before continuing with any physical activity program . WAIVER Signature of Client or Parent/Guardian * Clear If you are human, leave this field blank. 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