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2022 Par-Q

Name*

Email*

Has your doctor ever told you you have high blood pressure or a heart condition?*

Yes

Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?*

Yes

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?*

Yes

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*

Yes

Are you currently taking prescribed medication for a chronic condition?*

Yes

Do you currently (have or have you had within 12 months) a bone, joint or soft tissue (muscle, ligament or tendon) problem that could be made worse by becoming more physically active?*

Yes

Has your doctor ever said that you should only do medically supervised physical activity?*

Yes

2022 Par-Q+

1.) Do you have Arthritis, Osteoporosis, or Back Problems?*

Yes

1a.) 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)

Yes

1b.) 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)?*

Yes

1c.) Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*

Yes

2.) Do you currently have Cancer of any kind?*

Yes

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

Yes

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

Yes

3.) Do you have a Heart or Cardiovascular Condition?*

This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm

Yes

3a.) 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)

Yes

3b.) Do you have an irregular heart beat that requires medical management?*

e.g. atrial fibrillation, premature ventricular contraction

Yes

3c.) Do you have chronic heart failure?*

Yes

3d.) Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*

Yes

4.) Do you currently have high Blood Pressure?*

Yes

4a.) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?*

Answer NO if you are not currently taking medications with other treatments

Yes

4b.) Do you have a resting blood pressure equal to or greater than 160/90 mmHg with your without medication?*

Answer YES if you do not know your resting blood pressure

Yes

5.) Do you have any Metabolic Conditions?*

This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes

Yes

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

Yes

5b.) 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

Yes

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

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

Yes

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

Yes

6.) 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

Yes

6a.) 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.

Yes

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

Yes

7.) Do you have a Respiratory Disease?*

This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure

Yes

7a.) 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.

Yes

7b.) Has your doctor ever said that your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*

Yes

7c.) If asthmatic, do you currently have symptoms of chest titghtness, wheezing, laboured breathing, consistent cough (more than 2 days per week), or do have you used your rescue medication more than twice in the last week?*

Yes

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

Yes

8.) Do you have a Spinal Cord Injury?*

This includes Tetraplegia and Paraplegia

Yes

8a.) 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.

Yes

8b.) Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?*

Yes

8c.) Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*

Yes

9.) Have you had a Stroke?*

This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event

Yes

9a.) 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.

Yes

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

Yes

9c.) Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*

Yes

10.) Do you have any other medical condition not listed above or do you have two or more medical conditions?*

Yes

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 within the last 12 months?*

Yes

10b.) Do you have a medical condition that is not listed?*

(such as epilepsy, neurological conditions, kidney problems)

Yes

10c.) Do you currently live with two or more medical conditions?*

Yes

Please list your medical conditions and any related medications here:

One Per Line (Use the plus Icon to the right to add more)

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PAR-Q & PAR-Q+

2022 Par-Q

2022 Par-Q+

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