PARQ+

1
The statements and health questions used in this online PAR-Q+ are taken directly from the Physical Activity Readiness Questionnaire for Everyone (2021 PAR-Q+). 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. Please read the questions below carefully and answer each one honestly: check YES or NO. Please note that your answers will be verified with you before your initial appointment at Atlantic Exercise Physiology, LLC. Do you understand and wish to continue with the online PAR-Q+?* This field is required.
YESNO
2
Has your doctor ever said that you have a heart condition OR high blood pressure ?* This field is required.
Yes, Heart Condition
Yes, High Blood Pressure
Yes, Both
No
3
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?* This field is required.
YESNO
4
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).* This field is required.
YESNO
5
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?* This field is required.
YESNO
6
If you answered yes to question #4 (been diagnosed with another chronic medical condition), please list condition(s) here, otherwise type N/A:* This field is required.
7
Are you currently taking prescribed medications for a chronic medical condition?* This field is required.
YESNO
8
If you answered yes to question #6 (currently taking prescribed medications for a chronic medical condition), please list condition(s) and medications here, otherwise type N/A:* This field is required.
9
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.* This field is required.
YESNO
10
If you answered yes to question #8 (have a bone, joint, or soft tissue problem that could be made worse by becoming more physically active), please list condition(s) here, otherwise type N/A:* This field is required.
11
Has your doctor ever said that you should only do medically supervised physical activity?* This field is required.
YESNO
12
Congratulations! Since you answered NO to all the questions, you are cleared for physical activity. Please review and sign the participant declaration.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. 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 Atlantic Exercise Physiology, LLC may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.* This field is required.
Clear
13
Since you answered YES to one or more of the questions above, you must answer additional follow-up questions about your medical condition(s). Would you like to continue?* This field is required.
YESNO
14
Do you have Arthritis, Osteoporosis, or Back Problems?* This field is required.
YESNO
15
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)* This field is required.
YESNO
16
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)?* This field is required.
YESNO
17
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?* This field is required.
YESNO
18
Do you currently have Cancer of any kind?* This field is required.
YESNO
19
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?* This field is required.
YESNO
20
Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?* This field is required.
YESNO
21
Do you have a Heart or Cardiovascular Condition? (This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm).* This field is required.
YESNO
22
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)* This field is required.
YESNO
23
Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction)* This field is required.
YESNO
24
Do you have chronic heart failure?* This field is required.
YESNO
25
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?* This field is required.
YESNO
26
Do you have High Blood Pressure?* This field is required.
YESNO
27
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)* This field is required.
YESNO
28
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)* This field is required.
YESNO
29
Do you have any Metabolic Conditions? (This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes).* This field is required.
YESNO
30
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?* This field is required.
YESNO
31
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.* This field is required.
YESNO
32
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?* This field is required.
YESNO
33
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?* This field is required.
YESNO
34
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?* This field is required.
YESNO
35
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)* This field is required.
YESNO
36
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)* This field is required.
YESNO
37
Do you have Down Syndrome AND back problems affecting nerves or muscles?* This field is required.
YESNO
38
Do you have a Respiratory Disease? (This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure).* This field is required.
YESNO
39
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)* This field is required.
YESNO
40
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?* This field is required.
YESNO
41
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?* This field is required.
YESNO
42
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?* This field is required.
YESNO
43
Do you have a Spinal Cord Injury? (This includes Tetraplegia and Paraplegia)* This field is required.
YESNO
44
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)* This field is required.
YESNO
45
Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?* This field is required.
YESNO
46
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?* This field is required.
YESNO
47
Have you had a Stroke? (This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event).* This field is required.
YESNO
48
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)* This field is required.
YESNO
49
Do you have any impairment in walking or mobility?* This field is required.
YESNO
50
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?* This field is required.
YESNO
51
Do you have any other medical condition not listed above or do you have two or more medical conditions?* This field is required.
YESNO
52
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?* This field is required.
YESNO
53
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?* This field is required.
YESNO
54
Do you currently live with two or more medical conditions?* This field is required.
YESNO
55
If you answered yes to the question above, please list your medical condition(s) and any related medications here:* This field is required.
56
Congratulations! Since you answered NO to all the FOLLOW-UP questions about your medical condition, you are ready to become more physically activity. Please review and sign the participant declaration.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. 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 Atlantic Exercise Physiology, LLC may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.* This field is required.
Clear
57
You answered YES to one or more of the follow-up questions about your medical condition or are currently a physical therapy patient: You are eligible for the initial health assessment, however, you should seek medical clearance before becoming more physically active.* This field is required.
Clear
58
First Name* This field is required.
59
Last Name* This field is required.
60
Date of Birth* This field is required.
Date
Year
Month
Day
61
Today's Date
Date
Year
Month
Day
62
Parent/Guardian Signature* This field is required.
Clear
63
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
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India
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Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
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Uruguay
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Vanuatu
Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
64
Email* This field is required.
example@example.com
65
Phone Number* This field is required.
Please enter a valid phone number.
66
Sex assigned at birth* This field is required.
Male
Female
67
Current Weight* This field is required.
68
Current Height* This field is required.
69
Emergency Contact Name & Relationship* This field is required.
70
Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
71
How did you hear about Atlantic Exercise Physiology?* This field is required.
My PT told me about it
Website
My school
My gym
Advertisement
Picked up materials about it inside Atlantic PT Center
Other
72
How Many days a week do you exercise?* This field is required.
73
Would you like to increase the number of days per week that you exercise?* This field is required.
YESNO
74
How many days would per week would you like to exercise?* This field is required.
75
What is the primary goal you hope to achieve through our services?* This field is required.
muscle gain
fat loss
conditioning
76
SCROLL DOWN TO SIGN! HIPAA PRIVACY POLICY NOTICE I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Disclose health information in order to conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment both directly and indirectly. Disclose your health information in order to receive payment for the services we provide to you. Disclose your health information for normal healthcare operations such as quality assessments and physician certifications. PATIENT RIGHTS REGARDING MEDICAL INFORMATIONThe Right to Inspect and Copy Your Information: You may review and copy your medical records and information. The Right to Amend: You may ask that we amend your health information if you believe that your information is incomplete or incorrect. The Right to Request Restrictions: You may request a restriction or limitation on how and what health information we disclose regarding you for treatment, payment of health operations or to your family or care-givers. The Right to Confidential Communications: You may request that we communicate with you about medical matters in a certain format or a specific location. The Right to Receive a Copy of this Notice: You may request and receive a copy of this notice (or our current notice) at any time by contacting this organization. SCROLL DOWN TO SIGN* This field is required.
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