Name *

First Name

Last Name

Has a doctor ever said that you have heart trouble? *

Yes

No

Do you frequently experience chest pain when you do physical activity? *

Yes

No

In the past month, have you had chest pain when you were not doing physical activity? *

Yes

No

Do you lose balance due to dizziness or have you lost consciousness? *

Yes

No

Do you have a joint or bone problem that could be made worse by physical activity? *

Yes

No

Is a doctor currently prescribing drugs for your blood pressure or heart condition? *

Yes

No

Do you know of any other reason why you should not participate in physical activity? *

Yes

No

Medical Disclaimer *

If you answered “Yes” to one or more questions, consult with your healthcare provider before engaging in physical activity. If you answered “No” to all questions, you are likely able to engage in physical activity but should still consult with healthcare providers if you have concerns or experience discomfort. I, the undersigned, understand that the PAR-Q is a self-assessment tool and does not replace medical advice. I affirm that the information provided is accurate, and I assume responsibility for my health and well-being.

I agree to the above medical disclaimer

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I agree to the Privacy Policy and consent to having this website store my submitted information so they can respond to my inquiry.