PHYSICAL ACTIVITY READINESS
QUESTIONNAIRE
PATIENT’S NAME: ________________________________________ DOB: _____________________ DATE: _____________________
HEALTH CARE PROVIDER’S NAME: _______________________________________
Please read the questions below carefully, and answer each one honestly. Please check YES or NO.
Yes No Has your health care provider ever said that you have a heart condition and that you should
only do physical activity recommended by a health care provider?
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 (for example, back, knee or hip) that could be made worse
by a change in your physical activity?
Yes No Is your health care provider currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition?
Yes No Do you know of any other reason why you should not do physical activity?
Excerpted from the Physical Activity Readiness Questionnaire (PAR-Q) © 2002. Used with permission from the Canadian
Society for Exercise Physiology.
PHYSICAL ACTIVITY READINESS
QUESTIONNAIRE
PATIENT’S NAME: ________________________________________ DOB: _____________________ DATE: _____________________
HEALTH CARE PROVIDER’S NAME: _______________________________________
Please read the questions below carefully, and answer each one honestly. Please check YES or NO.
Yes No Has your health care provider ever said that you have a heart condition and that you should
only do physical activity recommended by a health care provider?
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 (for example, back, knee or hip) that could be made worse
by a change in your physical activity?
Yes No Is your health care provider currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition?
Yes No Do you know of any other reason why you should not do physical activity?
Excerpted from the Physical Activity Readiness Questionnaire (PAR-Q) © 2002. Used with permission from the Canadian
Society for Exercise Physiology.
