Charneski Power PAR-Q
Charneski Power PAR-Q
Charneski Power PAR-Q
If you are planning to become much more physically active than you are now, start by answering the
seven questions in the box below. If you are between the ages of 16 and 69, the PAR-Q will tell you if 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. If you are younger than 16 years of age, this document is to be
completed by a parent or guardian.
Common sense is your best guide when you answer these questions. Please read the questions carefully
and answer each one honestly: Circle either YES or NO.
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
YES / NO
In the past month, have you had chest pain when you were not doing physical activity?
YES / NO
Do you lose your balance because of dizziness or do you ever lose consciousness?
YES / NO
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
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or
heart condition?
YES / NO
Do you know of any other reason why you should not do physical activity?
YES / NO
IF YOU ANSWERED YES TO ONE OR MORE OF THE
QUESTIONS:
Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or
BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you
answered YES.
You may be able to do any activity you want — as long as you start slowly and build up gradually. Or, you
may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds
of activities you wish to participate in and follow his/her advice.
SIGNATURE:
DATE:
Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed
and becomes invalid if your condition changes so that you would answer YES to any of the seven
questions.