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The Physical Activity Readiness Questionnaire for Everyone

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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

Please read the 7 questions below carefully and answer each one honestly: check YE N
YES or NO. S O
1) Has your doctor ever said that you have a heart condition OR high
blood pressure ?
2) Do you feel pain in your chest at rest, during your daily activities of living, OR
when you do physical activity?
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).
4) Have you ever been diagnosed with another chronic medical condition (other than
heart disease or high blood pressure)? PLEASE LIST CONDITION(S) HERE:
5) Are you currently taking prescribed medications for a chronic medical condition?
PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
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 answer NO if you had a problem in the past, but it does
not limit your current ability to be physically active. PLEASE LIST CONDITION(S) HERE:

7) Has your doctor ever said that you should only do medically supervised physical
activity?
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
Pages 2 and 3.
Start becoming much more physically active – start slowly and build up gradually.
Follow Global Physical Activity Guidelines for your age
([Link] 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 PROVIDER

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

Delay becoming more active if:

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You are currently experiencing a temporary illness, such as a cold or fever. It is best to wait until you feel better.

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You are pregnant. In this case, talk with your health care practitioner, physician, qualified exercise professional, and/or
complete the ePARmed-X+ at [Link] before becoming more physically active.
Your health changes. Answer the questions on Pages 2 and 3 of this document and/or talk to your health care
practitioner, physician, or qualified exercise professional before proceeding with any physical activity program.

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FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S)
1.

1a.
Q+
If the above condition(s) is/are present, answer questions 1a-1c If N
O
go to question 2
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 YES NO
treatments)

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 YES NO
defect (a crack in the bony ring on the back of the spinal column)?

1c Have you had steroid injections or taken steroid tablets regularly for more than YES
. 3 months?
2
. If the above condition(s) is/are present, answer questions If go to question 3
2a-2b
N
2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic,
O multiple
myeloma (cancer of plasma cells), head, and/or neck? YES NO

2b Are you currently receiving cancer therapy (such as chemotheraphy or YES

. radiotherapy)?

If the above condition(s) is/are present, answer questions If go to question 4

3a-3d N
O
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 YES NO
treatments)
YES NO
3b. Do you have an irregular heart beat that requires medical
management? (e.g., atrial fibrillation, premature ventricular
contraction)
3c Do you have chronic heart YES
. failure?
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
. If the above condition(s) is/are present, answer questions If go to question 5
4a-4b
N
4a. Do you have difficulty controlling your condition with medications or other O
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
. If the above condition(s) is/are present, answer questions If go to question 6
5a-5e N
O
5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other YES
prescribed
physician- therapies? 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, YES
nervousness,
abnormal unusual
sweating, irritability,
dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.
NO

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease YES
complications
and/or affecting your eyes, kidneys, OR the sensation in your toes and feet? NO

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

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Do you have any Mental Health Problems or Learning Difficulties? This includes

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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 N go to question 7
O
6a. Do you have difficulty controlling your condition with medications or other physician- YES
prescribed therapies? (Answer NO if you are not currently taking medications or other
treatments)
6b YE N
Do you have Down Syndrome AND back problems affecting nerves or muscles? S O
.
7. This includes Chronic Obstructive Pulmonary Disease, Asthma,
Pulmonary High Blood
Pressure
If the above condition(s) is/are present, answer questions
If go to question 8
7a-7d
N
7a. Do you have difficulty controlling your condition with medications or other physician-
O
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 YES NO
twice in the last week?

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

8 This includes Tetraplegia and

. Paraplegia If go to question 9
If the above condition(s) is/are present, answer questions 8a-8c
N
8a. Do you have difficulty controlling your condition with medications or other physician-
O
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 This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event

. If the above condition(s) is/are present, answer questions If N go to question 10
9a-9c O
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

.
Have you experienced a stroke or impairment in nerves or muscles in the NO
9c past 6 months?
10
.
If you have other medical conditions, answer questions If read the Page 4 recommendations
10a-10c
N
10a. Have you experienced a blackout, fainted, or lost consciousness as a result of
O a head injury
within the last 12 months OR have you had a diagnosed concussion within the last 12 YES NO
months?
10b Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, YES
. kidney problems)?
YE N
10c Do you currently live with two or more medical conditions? S O
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GO to Page 4 for recommendations about your
current medical condition(s) and sign the PARTICIPANT
DECLARATION.

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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 [Link] and/or visit a qualified exercise professional to work through the ePARmed-X+ and for
further information.

Delay becoming more active if:

You are currently experiencing a temporary illness, such as a cold or fever. It is best to wait until you feel
better.
You are pregnant. In this case, talk to your health care practitioner, physician, qualified exercise
professional, and/or complete the ePARmed-X+ at [Link] before becoming more
physically active.
Your health changes. Talk to your health care practitioner, physician, 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 PROVIDER

For more information, please contact [Link]

Email:
eparmedx@[Link]
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Citation for PAR-Q+
Warburton DER, Jamnik VK, Bredin SSD, and Gledhill N on behalf of the PAR-Q+
Collaboration. The PAR-Q+ was created using the evidence-based AGREE process (1) by the
The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and Electronic Physical
Activity Readiness Medical Examination (ePARmed-X+). Health & Fitness Journal of PAR-Q+ Collaboration chaired by Dr. Darren E. R. Warburton with Dr. Norman
Canada 4(2):3-23, 2011.
Gledhill, Dr. Veronica Jamnik, and Dr. Donald C. McKenzie (2). Production of this
Key References document has been made possible through financial contributions from the
Public Health Agency of Canada and the BC Ministry of Health Services. The
views expressed herein do not necessarily represent the views of the Public
Health Agency of Canada or the BC Ministry of Health Services.
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.

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