NASM PAR-Q Information

Name *

First Name

Last Name

D.O.B

MM

DD

YYYY

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

Yes

No

2) Do you feel pain in your chest when you perform physical activity? *

Yes

No

3) In the past month, have you had chest pain when you were not performing any 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 any medication for your blood pressure or for a heart condition? *

Yes

No

7) Do you know of any other reason why you should not engage in physical activity? *

Yes

No

2) Does your occupation require extended periods of sitting?

Yes

No

Varies

3) Does your occupation require extended periods of repetitive movements?

Yes

No

4) Does your occupation require you to wear shoes with a heel or dress shoes?

Yes

No

5) Does your occupation cause you anxiety or mental stress?

Yes

No

6) Do you partake in any recreational activities (golf, tennis, skiing, etc.)?

Yes*

No

7) Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)?

Yes*

No

8) Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?

Yes*

No

9) Have you ever had any surgeries?

Yes*

No

10) Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes?

Yes*

No

11) Are you currently taking any medication?

Yes*

No