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NEW CLIENT REGISTRATION FORM
Physical Activity Readiness Questionnaire (PAR-Q)
First name
Last name
Email
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Select Yes or No
Do you feel pain in your chest when you do physical activity?
Select Yes or No
In the past month, have you had chest pain when you were not doing physical activity?
Select Yes or No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Select Yes or No
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in physical activity?
Select Yes of No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Select Yes or No
Do you know of any other reason why you should not do physical activity?
Select Yes or No
Your Signature
Clear
Select a date
Submit
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