If you were asked to complete this form on paper, please download this copy for printing.



Medical Information

Please provide additional information regarding your reasons for seeing the above specialists

Medical History and Present Medical Condition Questionnaire

In order for you to gain the most benefit from this program, we encourage you to answer all of the following questions. If you are uncomfortable with answering a particular question, feel free to leave it blank. Please explain all YES answers at the end of this questionnaire.

Do you currently have or have you recently had any of the following?

Please answer the following questions honestly.

In one week I drink:

When were your most recent immunizations?

When were you most recent health maintenance screening tests?


fill in your approximate workout duration for each day (in minutes).

Please submit your current exercise regimen along with this form (type it up or write it out for us).



ie. 8:00am - Wake Up


Please rate each item from 0 to 5.
Sleep Quality:(0 = Poor Sleep, 5 = Very Good Sleep)
Tiredness:(0 = No Tiredness, 5 = Very Tired)
Willingness to Train:(0 = No Willingness, 5 = Very Excited to Train)
Appetite:(0 = No Appetite, 5 = Very Hungry)

Par-Q and You

If you answered Yes to one or more 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 gradual. 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. -Find out which community programs are safe and helpful for you.

If you answered No to All questions: DELAY BECOMING MUCH MORE ACTIVE: if you are not feeling well because of a temporary illness such as a cold or a fever - wait until you feel better; or if you are or may be pregnant - talk to your doctor before you start becoming more active.

If you answered NO honest􀀐 to iill PAR-Q questions, you can be reasonably sure that you can:
start becoming much more physically active - begin slowly and build up gradually. This is the safest and easiest way to go. take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.

PLEASE NOTE: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.