PARQ+ Name * First Name Last Name Email * Phone (###) ### #### Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when you do physical activity? * Yes No In the past month, have you had chest pain when you were not doing physical activity? * 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 drugs (for example, water pills) for your blood pressure or heart condition? * Yes No Do you currently receive medical care for or do you currently experience any Back/Spinal Pain? * Yes No Do you currently receive medical care for or do you currently experience any Headaches or Migraines? * Yes No Have you recently had Surgery? * Yes No Do you currently receive medical care for or do you currently have Diabetes? * Yes No Do you currently receive medical care for or do you currently experience any Asthma or Breathing Problems? * Yes No Are you currently Pregnant? * Yes No Have you recently given Birth? * Yes No If you answered yes to any of the previous questions, please provide more details * Do you know of any other reason why you should not do physical activity? * I confirm this is all true and correct as of todays date I confirm Thank you!
