New Client Physical Activity Readiness Questionnaire (PAR-Q)

Personal Training with Mark N. Degen, LMT, ACSM, ACE Physical Activity Screening Questionnaire

Contact Information
Name (required)
City (required)
State
Preferred Phone (required)
E-mail (required)

The Basics
Do you currently exercise?	Yes No
Rate your general level of fitness	Excellent Good Fair Poor
Resting measures (if known)
Date of Birth
Resting Heart Rate
Blood Pressure
Height
Weight

Medical History (Please fill out completely)
Has your doctor ever told you that you have heart trouble?	Yes No
Do you frequently have pains in your heart or chest?	Yes No
Do you often feel faint or have spells of severe dizziness?	Yes No
Has a doctor ever said your blood pressure was too high?	Yes No
Have you ever been diagnosed by a physician with a bone, joint, neurological, respiratory, circulatory, metabolic or other medical problem?	Yes No
Have you recently experienced unusual bone, neck, spine, joint or muscular pain (within the last 6 months)?	Yes No
If yes explain?
Have you recently had surgery within the past year?	Yes No
If yes, explain.
Are you currently taking any prescription medications such as those for heart problems, high blood pressure, high cholesterol, diabetes or any other condition?	Yes No
Is there any other medical reason not mentioned here why you should not follow an exercise program?	Yes No
If yes, explain.
Do you have any other medical condition that I should be aware of?	Yes No
If yes, explain.
If female, are you pregnant?	Yes No

Important
If you have answered “yes” to any of these questions, it will be necessary for your doctor to complete a Physician Medical History Questionnaire and return it to me prior to your initial exercise session. I will not be able to conduct any training until I am in receipt of these forms.

I acknowledge that I have read and understood the above questionnaire.

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