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PAR-Q
Informed Consent

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PAR-Q

Please answer the following questions to the best of your knowledge.

Name: *

Your name.

Physician Name:

Name of your physician, if applicable.

Physician Number:

Your physician's phone number

Heart Trouble:

No

Yes

Has your doctor ever informed you that you have heart trouble?

Chest Pain:

No

Yes

Do you frequently experience pains in your heart or chest?

Faint:

No

Yes

Do you often feel faint or have spells of severe dizziness?

Blood Pressure:

No

Yes

Has a doctor ever informed you that your blood pressure is too high?

Joint Pain:

No

Yes

Has your doctor ever informed you of a bone or joint problem may be aggravated or made worse by exercise?

Do you smoke?:

No

Yes

Over 65:

No

Yes

Are you over 65 and not accustomed to vigorous exercise?

Family History of Heart Attack or Stroke?:

No

Yes

Family History of High Blood Pressure?:

No

Yes

Family History of Diabetes?:

No

Yes

Other Reason:

No

Yes

Is there a good reason, not mentioned here, why you should not follow a vigorous conditioning program even if you wanted to?

Explanation:

If you answered, Yes, to any of these questions, please explain. You also may be required to complete a medical clearance form.

Other Medical History:

Please discuss any medical conditions that would be pertinent to designing, implementing and evaluating your training program.

Medication:

Please list any medications you are taking or have recently taken. Include dosage and purpose for taking it.

Injuries:

Elbow:

Indicate any injures. Please include cause of injury, treatment and current status.

Back:

Indicate any injures. Please include cause of injury, treatment and current status.

Abdominal:

Indicate any injures. Please include cause of injury, treatment and current status.

Wrist:

Indicate any injures. Please include cause of injury, treatment and current status.

Ankle:

Indicate any injures. Please include cause of injury, treatment and current status.

Shoulder:

Indicate any injures. Please include cause of injury, treatment and current status.

Hand:

Indicate any injures. Please include cause of injury, treatment and current status.

Hip:

Indicate any injures. Please include cause of injury, treatment and current status.

Knee:

Indicate any injures. Please include cause of injury, treatment and current status.

Neck:

Feet:

Indicate any injures. Please include cause of injury, treatment and current status.

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