This form is for trainer use. Its used to identify health risk factors as well as protect you from liabilty. This form is almost always required at most gyms as a prereq before exercise. It insures that someone starting an exercise program knows and understands what health challenges may need physicians referal etc.
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Physical Activity
Readiness Questionnaire
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READ: 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 their doctor before they start becoming more physically active.
If you are planning to become much more physically active than you are now, start by answering seven questions below. If you are between the ages of 15 and 69 the following questions will help determine whether you should first check with your doctor before beginning a fitness program.
Yes No
? ? 1. Has your doctor ever said you have a heart condition and that you should
only participate in physical activity recommended by a doctor?
? ? 2. Have you ever, or do you currently feel a pain in your chest when you
participate in physical activity?
? ? 3. In the past month have you had chest pain while you were not participating
in physical activity?
? ? 4. Do you lose your balance due to dizziness or do you ever lose
consciousness?
? ? 5. Do you have a bone or joint problem that could be aggravated due to
physical activity? ( back, knee, hip, etc.)
? ? 6. Is your doctor currently prescribing medication for blood pressure or heart
condition? If so please print here _________________________________.
? ? 7. Are you aware of any other reason why you shouldn’t start physical activity?
If you answered YES to one or more of the questions above:
ü Talk with your doctor by phone or in person BEFORE you start becoming more physically active or BEFORE you have a fitness professional appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.
ü You may be able to perform any activity you want – as long as you start slowly and build up gradually, however, you may need to restrict your activities to those that are safe for you. Talking with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
If you answered NO honestly to all questions, you can be reasonably sure that you can:
ü Start becoming much more physically active – beginning slowly and building up gradually. This is the safest and easiest way to go.
ü It is important to take your blood pressure. If your reading is over 140/90 talk with your doctor before becoming physically active.
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Delay becoming more active:
ü If you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better; or
ü 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 professional and health professional Ask whether you should change your physical activity plan.
Informed use of the Questionnaire: If in doubt after completing this questionnaire, consult your physician prior to physical activity.
I have read, understood, and completed this questionnaire honestly. Any questions I had were answered to my full satisfaction.
________________________________________________________________________
Name
________________________________________________________________________
Signature Date
________________________________________________________________________
Signature of Parent or Guardian Witness
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Note: This Physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.
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Jonathan Clegg
Certified Personal Trainer
(408) 710-3984
