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SCHEDULE
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About
Contact
Par-Q Form
First name
*
Last name
*
Age
*
Email
*
Phone
*
Birthday
Month
Day
Year
Emergency Contact Person
*
Emergency Contact Number
*
Do you have a heart condition or cardiovascular disorder?
*
Yes
No
Other
Explain
Did a doctor advise you to limit physical activity and only perform the recommended activities by a professional?
*
Yes
No
Other
Is there any chest pain when you're doing any physical activity?
*
Yes
No
Other
Explain
Do you usually lose your balance due to being dizzy or even lose your consciousness?
*
Yes
No
Other
Explain
Are you experiencing bone or joint problems in general or during physical activity?
*
Yes
No
Other
Explain
Do you have pain, tightness, or achiness in your body?
Yes
No
If yes, explain
Are you currently taking medications for your blood pressure or heart condition?
*
Yes
No
Is there any reason why you should not do physical activities?
*
Yes
No
I confirmed that all the information in this form is accurate and true
*
Yes
No
Signature
*
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