Please complete the following form.

Par - Q

First Name

Last name

Has your Doctor ever said you have a heart condition, high blood pressure or should only participate in medically supervised activity?

Yes

No

Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?

Yes

No

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?

Yes

No

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? Please explain.

Are you currently taking any medications or undergoing any treatments for a medical condition? Please list here as well as any side effects you may be experiencing.

Do you currently have or have had a bone, joint or soft tissue (muscle, connective tissue) problem that could be made worse by physical activity and/or have Arthritis, Osteoporosis or Back problem?

Yes

No

Have you suffered a stroke or TIA?

Yes

No

Have you ever had an injury to your spinal cord, head or neck, ex. concussion?

Yes

No

Please share any important details regarding your health.