Please answer ALL of the following questions:

    Are you currently under a doctor's care? YesNo

    Have you ever had an exercise stress test? YesNoDon't Know
    If Yes, were the resultsNormalAbnormal

    Do you take any medications on a regular basis? YesNo

    Have you recently been hospitalised? YesNo

    Do you smoke? YesNo
    Are you pregnant? YesNoNot applicable
    Do you drink alcohol more than three times per week? YesNo
    Is your stress level high? YesNo
    Are you moderately active on most days of the week? YesNo

    Do you have:
    High Blood Pressure? YesNo
    High Cholesterol? YesNo
    Diabetes? YesNo

    Is there any history of any parents or siblings who, prior to the age 55 had:
    A heart attack? YesNo
    A stroke? YesNo
    High Blood Pressure? YesNo
    High Cholesterol? YesNo
    Known Heart Disease? YesNo
    Rheumatic Heart Disease YesNo
    A Heart Murmur?YesNo
    Chest Pain with Exertion? YesNo
    Irregular Heartbeat or Palpitations? YesNo
    Lightheadedness or Fainting? YesNo
    Unusual Shortness of Breath?YesNo
    Cramping Pains in Legs or Feet? YesNo
    Other Metabolic Disorders? (thyroid, kidneys etc) YesNo
    Asthma? YesNo
    Back Pain (upper, middle or lower)? YesNo
    Other Joint Pain? (please explain below) YesNo
    Muscle Pain or any injury (please explain below)YesNo

    If you answered YES to one or more of the above questions, you should:
    Talk to you doctor before you become more physically active. Tell your doctor about this Par-Q form and explain which question(s) you answered yes.
    You may be able to any any activity you want - as long as you start off slowly and build up gradually. Or you may need to restrict to those that are safe for you. Talk to your doctor about the type of activities you wish to participate in and follow your doctor's advice closely.