Physical Activity Readiness Questionnaire (PAR-Q) Physical Activity Readiness Questionnaire (PAR-Q) Regular physical activity can be fun and is an integral key to a healthy lifestyle. As a result, people are starting to become more active every day. Being more active is very safe for most individuals. However, some people should check with their doctor before participating in a workout program. Please answer the questions listed below. If you are between the ages of 18 and 69, then this PAR-Q will determine if you need to check with your doctor before beginning to participate in a fitness training program. If you are 70 years of age or older, you will need to receive clearance from your physician to participate in personal training with Kroger Enterprises, LLC dba Sozo Health and Fitness. Please read the questions carefully and answer each one honestly. Write YES or NO 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? * Yes No 2. Do you feel pain in your chest when you do physical activity? * Yes No 3. In the past month, have you had chest pain when you were not doing physical activity? * Yes No 4. Do you lose your balance because of dizziness or do you ever lose consciousness? * Yes No 5. Do you have a bone or joint problem (e.g. back, knee, or hip) that could be made worse by a change in your physical activity? * Yes No 6. Is your doctor currently prescribing drugs (e.g. water pills) for your blood pressure or heart condition? * Yes No 7. Do you know of any other reason why you should not do physical activity? * Yes No If you answered YES to one or more questions: Please download and complete the Physician's Clearance Form we have provided for you in the forms section. 1. Talk with your doctor by phone or in-person in order to be cleared for participation in fitness training by Kroger Enterprises, LLC dba Sozo Health and Fitness. Tell your doctor about the PAR-Q and about the questions to which you answered YES. 2. Obtain from your Doctor his/her clearance to participate in personal training sessions with Kroger Enterprises, LLC dba Sozo Health and Fitness. 3. Consult your doctor about the activities you wish to participate in and follow his/her advice. If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can: 1. Start becoming more physically active – begin slowly/build gradually. 2. Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming more physically active. Note: If your health changes so that you then answer YES to any of the above questions, please consult with your doctor for a physical evaluation and request another PAR-Q from Kroger Enterprises, LLC dba Sozo Health and Fitness. I understand that a facsimile, electronic, pdf or DocuSigned signature will have the same force and effect as an original. Client's Signature * Date of Birth * Print Name * Date * Email * If under the age of 18, Signature of Parent or Guardian (If not, type N/A) * Print Name (If not, type N/A) * Email Submit
