Par-Q Form

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Par-Q Form

West Coast
Kinesiology
Services Ltd.

Head Office:
The Leisure Centre,
11925 Haney Place,
Maple Ridge, B. C.
V2X 6G2

Tel.: (604) 467- 4675
Fax: (604) 467- 5830

PAR - Q - & YOU
(A Questionnaire for People Aged 15 to 69)

Regular physical activity is fun and healthy, and increasingly more people are starting to
become more active every day. Being more active is very safe for most people. However,
some people should check with your doctor before you start. If you are over 69 years of
age, and you are not used to being very active, check with your doctor.

Common sense is your best guide when you answer these questions. Please read the
questions carefully and answer each one honestly: Select YES or NO

	Please select either Yes or No.
	1. Has your doctor ever said that you have a condition and that you should only do physical activity recommended by a doctor?
	2. Do you feel pain in your chest when you do physical activity?
	3. In the past month, have you had chest pain when you were not doing physical activity?
	4. Do you lose your balance because of dizziness or do you ever lose consciousness?
	5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
	6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
	7. Do you know of any other reason why you should not do physical activity?

If you answered YES to one or more questions

Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.
	You may be able to do any activity you want - as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
	Find out which community programs are safe and helpful to you.

If you answered NO to all questions

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:

	start becoming much more physically active - begin slowly and build up gradually. This is the safest and easiest way to go.
	take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.

DELAY BECOMING MUCH MORE ACTIVE:

	If you are not feeling well because of a temporary illness such a cold or a fever - wait until you feel better; or
	If you are or may be pregnant - talk to your doctor before you start becoming more active.

Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professionals.

Informed use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability to persons who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity.

Note: If the PAR-Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section may be used for legal or administrative purposes.

I have read, understood and completed this questionnaire. Any questions I had were answered
to my full satisfaction.

	Name: (first and last)

	Age:

	Telephone: (include area code)

	Preferred Time to contact you:


	Email:


	Name of Parent or Guardian: (for participants under the age of majority)


	Sport level of play:



	Current Programs:


	Training Goals:
The information you submit will remain confidential and will only be seen by trainers and therapists at West Coast Kinesiology.

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