2021 PAR-Q+ Form

To participate in our classes please fill out the following medical form

1) Has your doctor ever said you have a heart condition or high blood pressure?
2) Have you ever felt pain in your at rest, during daily activities orliving, OR when you do physical activity?
3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)
5) Are you currently taking prescribed medications for a chronic medical condition?
6) Do you currently have (or have had within 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?
7) Has your doctor ever said that you should only do medically supervised physical activity?
Did you answer YES to any of the above questions?
1) Do you have Arthritis, Osteoporosis, or Back Problems?
1.a) Do you have difficulty controlling your condition with medications or other physicial prescribed therapies?
1.b) Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displace vertebra (e.g.,spondylolisthesis), and/or spondylolysis/par defect (a crack in the boney ring on the back of the spinal colum)?
1.c) Have you ever had steroid injections or taken steroid tablets regualry for more than 3 months?
2) Do you currently have Cancer of any kind?
2.a) Does you cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?
2.b) Are currently receiving cancer therapy (such as chemotherapy or radio therapy)?
3) Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm
3.a) Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
3.b) Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)
3.c) Do you have chronic heart failure?
3.d) Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?
4) Do you currently have High Blood Pressure?
4.a) Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
4.b) Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)
5) Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes
5.a) Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician- prescribed therapies?
5.b) Do you often su#er from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, di!culty speaking, weakness, or sleepiness.
5.c) Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications a#ecting your eyes, kidneys, OR the sensation in your toes and feet?
5.d) Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?
5.e) Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?
6) Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome
6.a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
6.b) Do you have Down Syndrome AND back problems affecting nerves or muscles?
7) Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure
7.a) Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
7.b) Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?
7.c) 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?
7.d) Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?
8) Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia
8.a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
8.b) Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?
8.c) Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?
9) Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event
9.a) Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)
9.b) Do you have any impairment in walking or mobility?
9.c) Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?
10) Do you have any other medical condition not listed above or do you have two or more medical conditions?
10.a) 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?
10.b) Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?
10.c) Do you currently live with two or more medical conditions?

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 fitness center may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Thanks for submitting!