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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:

Par-Q Form