New Client Assessment Form

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

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

YesNo

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

YesNo

In the past month, have you had chest pain when you were not performing any physical activity?

YesNo

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

YesNo

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

YesNo

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

YesNo

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

YesNo

If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

GENERAL & MEDICAL QUESTIONNAIRE

Occupational Questions

Does your occupation require extended periods of sitting?

YesNo

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

YesNo

Does your occupation cause you anxiety (mental stress)?

YesNo

Recreational Questions

Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.)

YesNo

Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.)

YesNo

Medical Questions

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.)

YesNo

Have you ever had any surgeries? (If yes, please explain.)

YesNo

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? (If yes, please explain.)

YesNo

Are you currently taking any medication? (If yes, please list.)

YesNo