205 S. Salina Street
Syracuse
315.426.8917

Par Q Form

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Full Name

Date of Birth

Contact Phone Number

Height

Weight

Healthcare Provider

Provider Phone Number

Questions

Has your healthcare provider ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

Yes

Do you feel pain in your chest when performing physical activity?

Yes

Have you experienced chest pain when NOT performing physical activity in the last month?

Yes

Do you lose your balance because of dizziness or have you lost consciousness recently?

Yes

Do you have any bone or joint problems (back, knee, hip, etc.) such as arthritis, which could be aggravated through physical activity?

Yes

Is your doctor currently prescribing you any medications for high blood pressure or a heart condition?

Yes

Is there any reason why you should not participate in physical activity?

Yes

Do you currently exercise on a regular basis (3+ times per week)?

Yes

If "Yes" to any of the questions, please explain:

If "No" to all the questions, please explain:

Electronic Signature

Signature Date:

What is the color of the sky? *

Just making sure you are a human.

205 S. Salina Street
Syracuse
315.426.8917

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