ReleasePar-QPar-Q PHYSICAL ACTIVITY READINESS QUESTIONNAIREPHYSICAL ACTIVITY READINESS QUESTIONNAIRE Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when you perform physical activity? * Yes No in the past month, have you had chest pain when you were not performing any physical activityI * Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? * Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? * Yes No Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? * Yes No Do you know of ANY reason why you should not engage in physical activity? * Yes NoIf 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 QUESTIONNAIREOccupational Questions What is your current occupation? * Does your occupation require extended periods of sitting? * Yes No Does your occupation require extended periods of repetitive movements? * Yes No Please Explain * Does your occupation require you to wear shoes with a heel? (dress shoes) * Yes No Does your occupation cause you anxiety or mental stress? * Yes NoRecreational Questions Do you partake in any recreational activities? * Yes No(Golf, Tennis, skiing, Etc..) Please Explain * Do you have any hobbies? * Yes No(Reading, Gardening, Working on cars, Surfing the internet, Etc..) Please Explain * Medical Questions Have you ever had any pain or injuries? * Yes No(ankle, knee, hip, back, shoulder, etc..) Please Explain * Have you every had any surgeries? * Yes No Please Explain * Has a medical doctor ever diagnosed you with a chronic disease? * Yes No(Coronary heart disease, heart disease, coronary artery disease, high blood pressure, high cholesterol, diabetes, Etc..) Please Explain * Are you currently taking any medications? * Yes No(Coronary heart disease, heart disease, coronary artery disease, high blood pressure, high cholesterol, diabetes, Etc..) Please List * SubmitΔ
