Program Aplication Form - Hamidreza Khalounejad

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2022 PAR-Q+
The Physical Activity Readiness Questionnaire for Everyone

The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.

GENERAL HEALTH QUESTIONS

1) Has your doctor ever said that you have a heart condition OR high blood pressure

Yes No

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

Yes No

3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

Yes No

4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? PLEASE LIST CONDITION(S) HERE:

Yes No

5) Are you currently taking prescribed medications for a chronic medical condition? PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:

Yes No

6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? PLEASE LIST CONDITION(S) HERE:

Yes No

7) Has your doctor ever said that you should only do medically supervised physical activity?

Yes No

If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION. You do not need to complete Steps 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.
Follow Global Physical Activity Guidelines for your age (www.who.int/publications/i/item/9789240015128).
You may take part in a health and fitness appraisal.
If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.
If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

NAME

DATE

SIGNATURE

WITNESS

SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDE

If you answered YES to one or more of the questions above, COMPLETE STEP 2 AND 3.

Delay becoming more active if:

You have a temporary illness such as a cold or fever; it is best to wait until you feel better.
You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.
Your health changes - answer the questions on Steps 2 and 3 of this document and/or talk to your doctor or a qualified exercise professional before continuing with any physical activity program.

FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S)

1. Do you have Arthritis, Osteoporosis, or Back Problems? If the above condition(s) is/are present, answer questions 1a-1c. If NO, go to question 2

Yes No

1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes No

1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

Yes No

1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

Yes No

2. Do you currently have Cancer of any kind? If the above condition(s) is/are present, answer questions 2a-2b. If NO, go to question 3

Yes No

2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?

Yes No

2b. Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?

Yes No

3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm If the above condition(s) is/are present, answer questions 3a-3d. If NO, go to question 4

Yes No

3a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes No

3b. Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction)

Yes No

3c. Do you have chronic heart failure?

Yes No

3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

Yes No

4. Do you currently have High Blood Pressure? If the above condition(s) is/are present, answer questions 4a-4b. If NO, go to question 5

Yes No

4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes No

4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)

Yes No

5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes If the above condition(s) is/are present, answer questions 5a-5e. If NO, go to question 6

Yes No

5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician- prescribed therapies?

Yes No

5b. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.

Yes No

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?

Yes No

5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?

Yes No

5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

Yes No

6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome If the above condition(s) is/are present, answer questions 6a-6b. If NO, go to question 7

Yes No

6a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes No

6b. Do you have Down Syndrome AND back problems affecting nerves or muscles?

Yes No

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure If the above condition(s) is/are present, answer questions 7a-7d. If NO, go to question 8

Yes No

7a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes No

7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

Yes No

7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

Yes No

7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

Yes No

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia If the above condition(s) is/are present, answer questions 8a-8c. If NO, go to question 9

Yes No

8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes No

8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?

Yes No

8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?

Yes No

9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event If the above condition(s) is/are present, answer questions 9a-9c. If NO, go to question 10

Yes No

9a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes No

9b. Do you have any impairment in walking or mobility?

Yes No

9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

Yes No

10. Do you have any other medical condition not listed above or do you have two or more medical conditions? If you have other medical conditions, answer questions 10a-10c. If NO, read the Step 4 recommendations

Yes No

10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?

Yes No

10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?

Yes No

10c. Do you currently live with two or more medical conditions?

Yes No

PLEASE LIST YOUR MEDICAL CONDITION(S) AND ANY RELATED MEDICATIONS HERE:

GO to Step 4 for recommendations about your current medical condition(s) and sign the PARTICIPANT DECLARATION.

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

It is advised that you consult a qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs.
You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.
As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.
If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

Delay becoming more active if:

You have a temporary illness such as a cold or fever; it is best to wait until you feel better.
You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.
Your health changes - talk to your doctor or qualified exercise professional before continuing with any physical activity program.

You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted.
The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire, consult your doctor prior to physical activity.

PARTICIPANT DECLARATION

All persons who have completed the PAR-Q+ please read and sign the declaration below.
If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

NAME

DATE

SIGNATURE

WITNESS

SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDE

Key References
1. Jamnik VK, Warburton DER, Makarski J, McKenzie DC, Shephard RJ, Stone J, and Gledhill N. Enhancing the effectiveness of clearance for physical activity participation; background and overall process. APNM 36(S1):S3-S13, 2011.
2. Warburton DER, Gledhill N, Jamnik VK, Bredin SSD, McKenzie DC, Stone J, Charlesworth S, and Shephard RJ. Evidence-based risk assessment and recommendations for physical activity clearance; Consensus Document. APNM 36(S1):S266-s298, 2011.
3. Chisholm DM, Collis ML, Kulak LL, Davenport W, and Gruber N. Physical activity readiness. British Columbia Medical Journal. 1975;17:375-378.
4. Thomas S, Reading J, and Shephard RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Canadian Journal of Sport Science 1992;17:4 338-345.