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	Florida Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
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	Month January February March April May June July August September October November December Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
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
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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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