Physical Activity Readiness Questionnaire 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 YES or NO. 1) Has your doctor ever said that you have a heart condition? YESNO 2) Has your doctor ever said that you have high blood pressure? YESNO 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). YESNO 4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? YESNO Please list condition(s) here: 5) Are you currently taking prescribed medications for a chronic medical condition? YESNO Please list condition(s) 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. YESNO Please list condition(s) here: 7) Has your doctor ever said that you should only do medically supervised physical activity? YESNO If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the Participant Declaration at the bottom of this page. You do not need to complete the Follow-up Questions About Your Medical Conditions(s). Start becoming much more physically active – start slowly and build up gradually. Follow Global Physical Activity Guidelines for your age. 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. If you answered YES to one or more of the questions above, complete the Follow-up Questions About Your Medical Conditions(s) below. 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, and/or qualified exercise professional before becoming more physically active. Your health changes - answer the questions below under Follow-up Questions About Your Medical Conditions(s) and/or talk to your doctor or a qualified exercise professional before continuing with any physical activity program. Follow-up Questions About Your Medical Conditions(s) 8) Do you have Arthritis, Osteoporosis, or Back Problems? YESNO If the above condition(s) is/are present, answer questions 8a-8c. If NO go to question 9. 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) YESNO 8b) 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)? YESNO 8c) Have you had steroid injections or taken steroid tablets regularly for more than 3 months? YESNO 9) Do you currently have Cancer of any kind? YESNO If the above condition(s) is/are present, answer questions 9a-9b. If NO go to question 10. 9a) Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck? YESNO 9b) Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)? YESNO 10) Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm YESNO If the above condition(s) is/are present, answer questions 10a-10d. If NO go to question 11. 10a) 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) YESNO 10b) Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction) YESNO 10c) Do you have chronic heart failure? YESNO 10d) Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months? YESNO 11) Do you currently have High Blood Pressure? YESNO If the above condition(s) is/are present, answer questions 11a-11b. If NO go to question 12. 11a) 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) YESNO 11b) 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) YESNO 12) Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes YESNO If the above condition(s) is/are present, answer questions 12a - 12e. If NO go to question 13. 12a) Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician- prescribed therapies? YESNO 12b) 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. YESNO 12c) 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? YESNO 12d) Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)? YESNO 12e) Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future? YESNO 13) 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 YESNO If the above condition(s) is/are present, answer questions 13a - 13b. If NO go to question 14. 13a) 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) YESNO 13b) Do you have Down Syndrome AND back problems affecting nerves or muscles? YESNO 14) Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure YESNO If the above condition(s) is/are present, answer questions 14a - 14d. If NO go to question 15. 14a) 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) YESNO 14b) Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy? YESNO 14c) 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? YESNO 14d) Has your doctor ever said you have high blood pressure in the blood vessels of your lungs? YESNO 15) Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia YESNO If the above condition(s) is/are present, answer questions 15a - 15c. If NO go to question 16. 15a) 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) YESNO 15b) Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting? YESNO 15c) Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysretlexia)? YESNO 16) Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event YESNO If the above condition(s) is/are present, answer questions 16a - 16c. If NO go to question 17. 16a) 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) YESNO 16b) Do you have any impairment in walking or mobility? YESNO 16c) Have you experienced a stroke or impairment in nerves or muscles in the past 6 months? YESNO 17) Do you have any other medical condition not listed above or do you have two or more medical conditions? YESNO If the above condition(s) is/are present, answer questions 17a - 17c. If NO go to Recommendations 17a) 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? YESNO 17b) Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)? YESNO 17c) Do you currently live with two or more medical conditions? YESNO Please list your medical condition(s): And any related medications here: Recommendations If you answered NO to all of the Follow-up Questions About Your Medical Conditions(s), 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. 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 and/or a qualified exercise professional 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. Studio3 assumes no liability for persons who undertake physical activity and/or make use of the Studio3 Physical Activity Readiness Questionnaire. If in doubt after completing the questionnaire, consult your doctor prior to physical activity. Participant Declaration All persons who have completed the Studio3 Physical Activity Readiness Questionnaire 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. YES, 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 Email
