Health Par-Q

This form includes various questions regarding your physical health. Please answer every question as accurately as possible.

Name *
Do you have any personal history of heart disease (coronary or atherosclerotic disease)? *
Any personal history of diabetes or other metabolic disease (thyroid,renal,liver)?
Any personal history of pulmonary disease, asthma,interstitial lung disease or cystic fibrosis?
Have you experienced pain or discomfort in your chest apparently due to blood flow deficiency?
Any unaccustomed shortness of breath (perhaps during light exercise)
Do you have problems with dizziness or fainting?
Do you have difficulty breathing while standing or sudden breathing problems at night? *
Have you experienced a rapid throbbing or fluttering or the heart? *
Do you suffer from ankle edema (swelling of the ankles)? *
Have you experienced severe pain in leg muscles during walking ? *
Do you have a known heart murmur? *
Has your HDL (the"good" cholesterol) been measured at greater then 60 mg/dl? *
Would you characterize your lifestyle as "sedentary"? *
Have you had a high fasting blood glucose level on 2 or ore occasions (>=110mg/dl)? *
Are you 20% or more overweight or have you been told your "BMI" was greater then 30? *
Have you been assessed as hypertensive on at least 2 occasions (systolic>140mmHg or diastolic> 90mmHG)? *
Do you have any family history of cardiac or pulmonary disease prior to age 55? *
are you currently being treated for high blood pressure? *
Please check all conditions or diagnoses that apply:
Has a doctor imposed any activity restrictions? if so , please describe:
Please select any medications you are currently using *
are you a cigarette smoker?
if so , when did you quit?
if so , when did you quit?
Do you / did you smoke?
Please rate your daily stress levels (select one):
Do you drink alcoholic beverages?
Dietary habits. Please select all that apply.
Please indicate any other medical conditions or activity restrictions that you may have , or any other information you feel is critical to understanding your readiness for exercise. it is important that this information be as accurate and complete as possible
what is your motivation level?
what is your confidence level?