Application

Being physically active is very safe for most people. Some people, however, should check with their doctors before they increase their current level of activity. The PAR-Q has been designed to identify the small number of adults for whom physical activity may be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Exercise is often an important part of treatment for conditions such as these, but you may have some limitations or special needs that your doctor can tell you about.

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes No

2. Do you feel pain in your chest when you do physical activity?

Yes No

3. In the past month, have you had chest pain when you were not doing physical activity?

Yes No

4. Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes No

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes No

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes No

7. Do you know of any other reason why you should not do physical activity?

Yes No

If you answered, “Yes,” to any of the questions in the list above, you must check in with your doctor and obtain medical clearance for exercise before you start any exercise program. Please also ask your physician to provide information in writing about specific exercise limitations you may have.

I answered No to all questions above OR I will provide medical clearance PRIOR to our first meeting.

Participant’s Name

Participant’s Birth Date

Participant’s Home Address

Participant’s Phone Number

In providing the information requested below, you will help your coach to better tailor a program to your needs and help them better prepare for your live appointments.

Please list and explain any diagnosed diseases or other chronic medical condition(s):

Please list any allergies you have, noting those that require immediate medical intervention:

Please list medications you are currently taking:

Please describe past surgeries, injuries, and other areas of limitation you’ve experienced over your lifetime, including recurring pain/discomfort:

I acknowledge that Starfish Strength Inc will retain a copy of this form for its records. I HAVE CAREFULLY READ, CLEARLY UNDERSTAND, AND HAVE TRUTHFULLY COMPLETED THIS QUESTIONNAIRE TO THE BEST OF MY KNOWLEDGE AND ABILITY.

Initial Questionaire

Physical Activity Readiness Questionnaire (PAR-Q)