Physical Activity Readiness Questionnaire+

1. Do you have Arthritis, Osteoporosis, or Back Problems? If the above condition(s) is/are present, answer questions 1a – 1c

Yes
No

1a. Do you have difficulty controlling your condition with medications or other physician prescribed therapies? Answer NO if you are not currently taking medications

Yes
No

1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancers, displaced vertebra (e.g. spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

Yes
No

2. Do you currently have cancer of any kind? If the above condition(s) is/are present, answer questions 2a-2b

Yes
No

2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?

Yes
No

2b. Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?

Yes
No

3. Do you have a Heart of Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure and/or Diagnosed Abnormality of Heart Rhythm? If the above condition(s) is/are present, answer questions 3a-3d

Yes
No

3a. Do you have difficulty controlling your condition with medications or other physician prescribed therapies? Answer NO if you are not currently taking medications

Yes
No

3b. Do you have an irregular heart beat that requires medical management? (e.g. atrial fibrillation, premature ventricular contraction)

Yes
No

3c. Do you have Chronic Heart Failure?

Yes
No

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. Do you currently have High Blood Pressure? If the above condition(s) is/are present, answer questions 4a – 1b

Yes
No

4a. Do you have difficulty controlling your condition with medications or other physician prescribed therapies? Answer NO if you are not currently taking medications

Yes
No

4b. Do you have a resting blood pressure equal to or greater than 160/90 mm HG with or without mediation? Answer YES if you do not know your resting blood pressure.

Yes
No

5. Do you have any Metabolic Conditions? This includes Type I, Type 2 Diabetes & Pre-Diabetes If the above conditions(s) is/are present answer questions 5a-5e.

Yes
No

5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?

Yes
No

5b. Do you 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?

Yes
No

5c. 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?

Yes
No

5d. Do you have other metabolic conditions such as current pregnancy-related diabetes, chronic kidney disease, or liver problems?

Yes
No

5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

Yes
No

6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia, Depressions, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome? If the above condition(s) is/are present, answer questions6a -6b

Yes
No

6a. Do you have difficulty controlling your condition with medications or other physician prescribed therapies? Answer NO if you are not currently taking medications

Yes
No

6b. Do you have Down Syndrome AND back problems affecting nerves or muscles?

Yes
No

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma and/or Pulmonary High Blood Pressure. If the above condition(s) is/are present, answer questions 7a-7dDo you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia, Depressions, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome? If the above condition(s) is/are present, answer questions6a -6b (copy)

Yes
No

7a. Do you have difficulty controlling your condition with medications or other physician prescribed therapies? Answer NO if you are not currently taking medications

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, labored breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

Yes
No

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

Yes
No

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia. If the above condition(s) is/are present, answer questions 8a-8c

Yes
No

8a. Do you have difficulty controlling your condition with medications or other physician prescribed therapies? Answer NO if you are not currently taking medications

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. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event? If the above condition(s) is/are present, answer questions 9a – 9c

Yes
No

9a. Do you have difficulty controlling your condition with medications or other physician prescribed therapies? Answer NO if you are not currently taking medications

Yes
No

9b. Do you have any impairment in walking or mobility?

Yes
No

9c. Do you have difficulty controlling your condition with medications or other physician prescribed therapies? Answer NO if you are not currently taking medications Do you have any impairment in walking or mobility? (copy)

Yes
No

10. Do you have any other medical condition not listed above or do you have two or more medical conditions noted above? If you have other medical conditions, answer questions 10a – 10b

Yes
No

10a. 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 with the last 12 months?

Yes
No

10b. Do you have a medical condition that is not listed? Please enter them here

If you answered YES ton one or more of the questions about your medical condition:
You should seek further information before becoming more physically active or engaging in a fitness appraisal. It is recommended that you visit a qualified exercise professional (with advanced university training) or your family physician for further information. This does not mean that you cannot perform any physical activities. We recommend that you only engage in low-intensity physical activity until you have received clearance from your physician and/or have met with a qualified exercise professional.

If you answered NO to all of the questions about your medical condition:

You are ready to become more physically active with the following recommendations: • If you are over the age of 45 and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

• You are encouraged to start slowly and build up gradually to 20 – 60 minutes of moderate intensity exercise, 3-5 days per week.

• Your exercise program should be tailored to your specific needs and should include a combination of aerobic, agility and muscle strengthening exercises.

I, the undersigned, have read, understood to my full satisfaction and completed the PAR-Q+ Form. I have answered each question truthfully, reflecting my current condition. I acknowledge that this physical activity clearance/recommendation is valid for a maximum of 6 months from the date it is completed and becomes invalid if my condition changes.

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