PAR-Q Form - The Good Companions

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Physical Activity Readiness Questionnaire

If you are planning to become much more physically active than you are now, start by answering the seven questions below. If you are between the ages of 15 and 69 and you answer YES to any of the following questions, you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: select 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 (for example, 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 (for example, water pills) for your blood pressure or heart condition?*

Yes
No

7. Is there anything else about your current health that could be a concern in a physical activity program?*

Please review the following user agreement carefully before signing up to any fitness or dance class.*

I acknowledge that I have read and fully agree to and accept the Terms of Use, Privacy Policy, and Disclaimer statements of The Good Companions.

By clicking on “Accept” you acknowledge that you have read and fully agree to and accept the Terms of Use, Privacy Policy, and Disclaimer statements of The Good Companions:
1. The Good Companions strongly recommends that you consult with your physician before beginning any exercise program. You should be in good physical condition and be able to participate in the exercise. The Good Companions and its fitness instructors are not licensed medical care providers and have no expertise in diagnosing, examining, or treating medical conditions of any kind, or in determining the effect of any specific exercise on a medical condition.

2. You understand that when participating in any exercise or exercise program, there is the possibility of physical injury. If you engage in any of The Good Companions fitness or dance class (exercise program), you agree that you do so at your own risk, are voluntarily participating in these activities, assume all risk of injury to yourself, and agree to release and discharge The Good Companions and its fitness instructors from any and all claims or causes of action, known or unknown, arising out of The Good Companions.

3. You understood and fully replied to the best of your knowledge to the Par-Q (Physical Activity Readiness Questionnaire) and the answers to all questions were negative. In the event that replies to some of the questions on the Par-Q were positive, it is your responsibility to follow up with your physician and inform the trainer of any limitations caused by your health condition(s).

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