Fillable January2020PARQ Plus Fillable

Fill Online, Printable, Fillable, Blank January2020PARQ Plus Fillable Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

January2020PARQ Plus Fillable

On average this form takes 25 minutes to complete

The January2020PARQ Plus Fillable form is 4 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 95 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
The Physical Activity Readiness Questionnaire for Everyone
The health benets of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in
physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor
OR a qualied exercise professional before becoming more physically active.
YES NO
Please read the 7 questions below carefully and answer each one honestly: check
YES
or
NO.
1) Has your doctor ever said that you have a heart condition OR high blood pressure ?
4) Have you ever been diagnosed with another chronic medical condition (other than heart disease
or high blood pressure)?
PLEASE LIST CONDITION(S) HERE:
5) Are you currently taking prescribed medications for a chronic medical condition?
7) Has your doctor ever said that you should only do medically supervised physical activity?
2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do
physical activity?
3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).
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?
Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.
PLEASE LIST CONDITION(S) HERE:
GENERAL HEALTH QUESTIONS
If you answered NO to all of the questions above, you are cleared for physical activity.
Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.
If you answered YES to one or more of the questions above, COMPLETE PAGES 2 AND 3.
Delay becoming more active if:
You have a temporary illness such as a cold or fever; it is best to wait until you feel better.
You are pregnant - talk to your health care practitioner, your physician, a qualied exercise professional, and/or complete the
ePARmed-X+ at www.eparmedx.com before becoming more physically active.
Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a qualied exercise
professional before continuing with any physical activity program.
Copyright © 2020 PAR-Q+ Collaboration
1 / 4
01-11-2019
PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Start becoming much more physically active – start slowly and build up gradually.
Follow Global Physical Activity Guidelines for your age (https://apps.who.int/iris/handle/10665/44399).
You may take part in a health and tness appraisal.
If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal eort exercise, consult a qualied exercise
professional before engaging in this intensity of exercise.
If you have any further questions, contact a qualied exercise professional.
PARTICIPANT DECLARATION
If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must
also sign this form.
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 community/tness center may retain a copy of this form for its records. In these instances, it will maintain the
condentiality of the same, complying with applicable law.
NAME ____________________________________________________
SIGNATURE ________________________________________________
SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER ____________________________________________________________
WITNESS _____________________________________
DATE __________________________
2020 PAR-Q+
1. Do you have Arthritis, Osteoporosis, or Back Problems?
1a. 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)
1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer,
displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the
back of the spinal column)?
1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?
If the above condition(s) is/are present, answer questions 1a-1c
If NO go to question 2
2. Do you currently have Cancer of any kind?
If the above condition(s) is/are present, answer questions 2a-2b
3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure,
Diagnosed Abnormality of Heart Rhythm
If the above condition(s) is/are present, answer questions 3a-3d
If the above condition(s) is/are present, answer questions 5a-5e
5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes
If NO go to question 3
If NO go to question 4
If NO go to question 6
4. Do you currently have High Blood Pressure?
If the above condition(s) is/are present, answer questions 4a-4b
4a. 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)
4b. 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)
If NO go to question 5
2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of
plasma cells), head, and/or neck?
2b. Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?
3a. 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)
3b. Do you have an irregular heart beat that requires medical management?
(e.g., atrial brillation, premature ventricular contraction)
3c. Do you have chronic heart failure?
3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical
activity in the last 2 months?
5a. Do you often have diculty controlling your blood sugar levels with foods, medications, or other physician-
prescribed therapies?
5b. 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.
5c. 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?
5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or
liver problems)?
5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?
2020 PAR-Q+
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S)
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Copyright © 2020 PAR-Q+ Collaboration
2 / 4
11-01-2019
If the above condition(s) is/are present, answer questions 7a-7d
If the above condition(s) is/are present, answer questions 8a-8c
If the above condition(s) is/are present, answer questions 9a-9c
If you have other medical conditions, answer questions 10a-10c
If NO
go to question 8
If NO go to question 9
If NO go to question 10
If NO read the Page 4 recommendations
2020 PAR-Q+
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
GO to Page 4 for recommendations about your current
medical condition(s) and sign the PARTICIPANT DECLARATION.
7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma,
Pulmonary High Blood Pressure
7a. 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)
7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require
supplemental oxygen therapy?
7c. 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?
7d. 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
8a. 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)
8b. Do you commonly exhibit low resting blood pressure signicant enough to cause dizziness, light-headedness,
and/or fainting?
8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic
Dysreexia)?
9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event
9a. 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)
9b. Do you have any impairment in walking or mobility?
9c. 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?
10a. 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?
10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?
10c. Do you currently live with two or more medical conditions?
PLEASE LIST YOUR MEDICAL CONDITION(S)
AND ANY RELATED MEDICATIONS HERE:
11-01-2019
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
If the above condition(s) is/are present, answer questions 6a-6b
If NO
go to question 7
6a. 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)
6b. Do you have Down Syndrome AND
back problems aecting nerves or muscles?
YES NO
YES NO
Copyright © 2020 PAR-Q+ Collaboration
3/ 4
2020 PAR-Q+
PARTICIPANT DECLARATION
NAME ____________________________________________________
SIGNATURE ________________________________________________
SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER ____________________________________________________________________
DATE _________________________________________
WITNESS ______________________________________
Copyright © 2020 PAR-Q+ Collaboration
4/ 4
For more information, please contact
Key References
www.eparmedx.com
Email: eparmedx@gmail.com
1. Jamnik VK, Warburton DER, Makarski J, McKenzie DC, Shephard RJ, Stone J, and Gledhill N. Enhancing the eectiveness of clearance for physical activity participation; background and overall process. APNM 36(S1):S3-S13, 2011.
2. Warburton DER, Gledhill N, Jamnik VK, Bredin SSD, McKenzie DC, Stone J, Charlesworth S, and Shephard RJ. Evidence-based risk assessment and recommendations for physical activity clearance; Consensus Document. APNM
36(S1):S266-s298, 2011.
3. Chisholm DM, Collis ML, Kulak LL, Davenport W, and Gruber N. Physical activity readiness. British Columbia Medical Journal. 1975;17:375-378.
4. Thomas S, Reading J, and Shephard RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Canadian Journal of Sport Science 1992;17:4 338-345.
Citation for PAR-Q+
Warburton DER, Jamnik VK, Bredin SSD, and Gledhill N on behalf of the PAR-Q+ Collaboration.
The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and Electronic Physical Activity
Readiness Medical Examination (ePARmed-X+). Health & Fitness Journal of Canada 4(2):3-23, 2011.
If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition,
you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:
If you answered YES to one or more of the follow-up questions about your medical condition:
You should seek further information before becoming more physically active or engaging in a tness appraisal. You should complete
the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com
and/or
visit a qualied exercise professional to work through the ePARmed-X+ and for further information.
It is advised that you consult a qualied exercise professional to help you develop a safe and eective physical
activity plan to meet your health needs.
You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise,
3-5 days per week including aerobic and muscle strengthening exercises.
As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.
If you are over the age of 45 yr and NOT
accustomed to regular vigorous to maximal eort exercise, consult a
qualied exercise professional before engaging in this intensity of exercise.
All persons who have completed the PAR-Q+ please read and sign the declaration below.
If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care
provider must also sign this form.
Delay becoming more active if:
You have a temporary illness such as a cold or fever; it is best to wait until you feel better.
You are pregnant - talk to your health care practitioner, your physician, a qualied exercise professional,
and/or complete the ePARmed-X+ at www.eparmedx.com
before becoming more physically active.
Your health changes - talk to your doctor or qualied exercise professional before continuing with any physical
activity program.
You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted.
The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who
undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire,
consult your doctor prior to physical activity.
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 community/tness center may retain a copy of this
form for records. In these instances, it will maintain the condentiality of the same, complying with applicable law.
The PAR-Q+ was created using the evidence-based AGREE process (1) by the PAR-Q+
Collaboration chaired by Dr. Darren E. R. Warburton with Dr. Norman Gledhill, Dr. Veronica
Jamnik, and Dr. Donald C. McKenzie (2). Production of this document has been made possible
through nancial contributions from the Public Health Agency of Canada and the BC Ministry
of Health Services. The views expressed herein do not necessarily represent the views of the
Public Health Agency of Canada or the BC Ministry of Health Services.
11-01-2019
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

January2020PARQ Plus Fillable

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document