Par-Q+ Fitness Questionnaire for BST

Personal Details

Name

Email Address

Phone

Are You Submitting Your Par-Q+ as an Individual or a Team? *Individual - A Person Looking to Participate in Personal Training - This includes 1 on 1 training, MAT sessions and semi private training (2, 3 and 4 person groups)Team - A Player who is a member of a Sports Team or Organization

Select Your TrainerChoose the trainer you are working with so that your information gets into the right hands. If your trainer isn't shown or you don't know, just choose OTHER.

General Health Quesitons

Please read the 7 questions below carefully and answer each one honestly.

1) Has your doctor ever said that you have a heart condition or high blood pressure? *YesNo

2) Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activities? *YesNo

3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? *YesNoPlease answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *YesNo

Please list condition(s) here:

5) Are you currently taking prescribed medications for a chronic medical condition? *YesNo

Please list condition(s) and medications here:

6) Do you currently have (or have had in 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? *YesNoPlease answer NO if you had a problem in the past, but it does NOT limit your current ability to be physically active.

Please list condition(s) here:

7) Has your doctor ever said that you should only do medically supervised physical activity? *YesNo

Green Section

If you answered NO to all of the questions above, you are cleared for physical activity.

SIGN PARTICIPATION DECLARATION

Please sign the participant declaration signature box below as you're ready to:

Start becoming much more physically active - start slowly and build up gradually.
Follow Global Physical Activity Guidelines for your age.
You may take part in a health and fitness appraisal.
If you are over the age of 45 years, 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.

Follow Up

Follow up questions about your medical condition(s).

IF YOU ANSWERED YES TO ONE OR MORE OF THE QUESTIONS ABOVE, PLEASE COMPLETE THE FOLLOWING:

1) Do you have Arthritis, Osteoporosis, or Back Problems?YesNoIf the above condition(s) is/are present, answer questions 1a-1c. If NO, go to question 2.

1a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?YesNo(Answer NO if you are not currently taking medications or other treatments)

1b) Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (ex spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?YesNo

1c) Have you had steroid injections or taken steroid tablets regularly for more than 3 months?YesNo

2) Do you currently have Cancer of any kind?YesNoIf yes, please answer 2a-2b. If no, go to question 3.

2a) Does your cancel diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?YesNo

2b) Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?YesNo

3) Do you have a heart of cardiovascular condition? This includes coronary artery disease, heart failure, diagnosed abnormality of heart rhythm?YesNoIf the above condition(s) is/are present, answer questions 3a-3d. If NO, go to question 4.

3a) Do you have difficulty controlling your condition with medication or other physician prescribed therapies?YesNo(Answer NO if you are not currently taking medications or other treatments)

3b) Do you have an irregular heart beat that requires medical management?YesNo(Ex: arterial fibrillation, premature ventricular contraction)

3c) Do you have chronic heart failure?YesNo

3d) Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?YesNo

4) Do you have high blood pressure?YesNoIf the above condition is present, answer 4a-4b. If NO, please go to 5.

4a) Do you have difficulty controlling your condition with medications or other physician prescribed therpaies?YesNo(Answer NO if you are not currently taking medications or other treatments)

4b) Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?YesNo(Answer YES if you do not know your resting blood pressure).

5) Do you have any metabolic conditions? This includes type 1/2 Diabetes & Pre-DiabetesYesNoIf the above condition(s) is/are present, answer 5a-5e. If NO, go to 6.

5a) Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed treatments?YesNo

5b) Do you often suffer from signs and symptoms of low blood sugar (hypoglycaemia) following exercise and/or during activities of daily living? Signs of hypoglycaemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light headedness, mental confusion, difficulty speaking, weakness, or sleepiness.YesNo

5c) Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, or the sensation in your toes and feet?YesNo

5d) Do you have other metabolic conditions (such as current pregnancy related diabetes, chronic kidney disease, or liver problems)?YesNo

5e) Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?YesNo

6) 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?YesNoIf any of the above conditions are present, please answer 6a-6b. If NO, go to 7.

6a) Do you have difficulty controlling your condition with medications or other physician prescribed therapies?YesNo(Answer NO if you are not currently taking medications or other treatments)

6b) Do you have down syndrome AND back problems affecting nerves or muscles?YesNo

7) Do you have a respiratory disease? This includes chronic obstructive pulmonary disease, asthma, pulmonary high blood pressure.YesNoIf any of the above conditions are present, please answer 7a-7d. If NO, go to 8.

7a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?YesNo(Answer NO if you are not currently taking medications or other treatments)

7b) Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?YesNo

7c) If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?YesNo

7d) Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?YesNo

8) Do you have a spinal cord injury? This includes tetraplegia and paraplegia.YesNoIf any of the above conditions are present, please answer 8a-8c. If NO, go to 9.

8a) 8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?YesNo(Answer NO if you are not currently taking medications or other treatments)

8b) Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?YesNo

8c) Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?YesNo

9) Have you had a stroke? This includes transient ischemic attack (TIA) or cerebrovascular event.YesNoIf any of the above conditions are present, please answer 9a-9c. If NO, go to 10.

9a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?YesNo(Answer NO if you are not currently taking medications or other treatments)

9b) Do you have any impairment in walking or mobility?YesNo

9c) Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?YesNo

10) Do you have any other medical condition not listed above or do you have two or more medical conditions?YesNoIf you have other medical conditions, answer 10a-10c. If NO, Please see recommendations below.

10a) 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?YesNo

10b) Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?YesNo

10c) Do you currently live with two or more medical conditions?YesNo

PLEASE LIST YOUR MEDICAL CONDITION(S) AND ANY RELATED MEDICATIONS HERE:

Summary Section

If you answered NO to all 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.

Summary Section

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.

Warning

Delay becoming 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

For Your Records

You are encouraged to keep a copy of the PAR-Q+ submission email that will be sent to you. You must use the entire questionnaire and NO changes are permitted.
The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire, consult your doctor prior to physical activity.

Participant Declaration

All persons who have completed the PAR-Q+ please read and sign the declaration below.
If 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 centre may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

Signature