Physical Activity Readiness Questionnaire

Physical Activity Readiness Questionnaire

Needing the consent of the participant to be at the school activity? This form will allow you to get their signature for the event. Form Preview
Physical Activity Readiness Questionnaire (PARQ)
  • Physical Activity Readiness Questionnaire (PARQ)

  • Please read the following questions carefully and check (X) next to the appropriate answers. Answer all questions honestly and to the best of your ability.

  •   Yes No
    Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or that you should only do physical activity recommended by a doctor?
    Do you feel pain in your chest when you do physical activity?
    In the past month, have you had chest pain when you were not doing physical activity?
    Do you lose your balance because of dizziness or do you ever lose consciousness?
    Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
    Do you have a diagnosed illness that could be made worse by physical activity?
    Is your doctor currently prescribing medication for your blood pressure or heart condition?
    Do you know of any other reason why you should not do physical activity?
  • Fitness Participation Agreement

    I have voluntarily chosen to participate in Adapted Fitness Program offered by Powered to Move. I have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent me from participation. I acknowledge that participation is at my own pace and comfort level and that I may discontinue my participation at any time. Furthermore, I agree to self-determine my exertion through good judgement and to discontinue any activity that exceeds my personal limitations. I understand that by signing this agreement that I hereby waive and release Powered to Move, its Board Members, staff, and all relevant employees in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation. I affirm that I have read and understand ths document and I wish to participate in fitness activities.

  • Clear
  •  -  - Pick a Date
  • Clear
  •  -  - Pick a Date
  • Should be Empty:
Now create your own JotForm - It's free! Create your own JotForm