Intake, classic form
PAR Q readiness questionnaire template (classic)
The seven question physical activity readiness questionnaire with doctor clearance, a guardian for minors and a signature.
12 questions, 11 required, as a classic form
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Every question
Client name (required)
Full name
1. Has a doctor ever said you have a heart condition or high blood pressure? (required)
Single choice: Yes, No
2. Do you feel pain in your chest at rest, during daily activities or when you exercise? (required)
Single choice: Yes, No
3. In the last 12 months, have you lost your balance because of dizziness, or lost consciousness? (required)
Single choice: Yes, No
4. Have you been diagnosed with any other long term medical condition, apart from heart disease or high blood pressure? (required)
Single choice: Yes, No
5. Are you taking prescribed medication for a long term medical condition? (required)
Single choice: Yes, No
6. Do you have a bone, joint or soft tissue problem that could be made worse by being more active? (required)
Single choice: Yes, No
7. Has a doctor ever said you should only exercise under medical supervision? (required)
Single choice: Yes, No
If you answered yes to any question, has your doctor cleared you to exercise? (required)
Single choice: Yes, I have clearance, Not yet, I will bring it to my first class, I answered no to all seven
Date (required)
Date
Parent or guardian (under 18s only)
Full name
Signature (required)
Signature
What you fill in
- [Your company]