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Metro42 Challenge Par-Q Form
Full Name
Email
Date of Birth
Contact Phone Number
Height
Weight
Healthcare Provider
Provider Phone Number
Metro Location
*
Downtown
Metro East
Questions
Has your healthcare provider ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when performing physical activity?
Yes
No
Have you experienced chest pain when NOT performing physical activity in the last month?
Yes
No
Do you lose your balance because of dizziness or have you lost consciousness recently?
Yes
No
Do you have any bone or joint problems (back, knee, hip, etc.) such as arthritis, which could be aggravated through physical activity?
Yes
No
Is your doctor currently prescribing you any medications for high blood pressure or a heart condition?
Yes
No
Is there any reason why you should not participate in physical activity?
Yes
No
Do you currently exercise on a regular basis (3+ times per week)?
Yes
No
If "Yes" to any of the questions, please explain:
If "No" to all the questions, please explain:
Electronic Signature:
Signature Date:
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
What is the opposite of hot?
*
Fill in the blank.
