Fitness Assessment

Client Readiness for Exercise

Name ________________________________________ Date __________

Age __________

Physical Activity Readiness Questionnaire (PAR-Q) YES NO Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

Do you feel pain in your chest when you perform physical activity?

In the past month, have you had chest pain when you were not performing any physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

Do you know of any other reason why you should not engage in physical activity?

If you have answered YES to one or more of the above questions, consult your physician before engaging in physical activity. Tell you physician which questions you answered

YES to. After medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

General and Medical History

Occupational What is your current occupation? _____________________________________________________________________________ Does your occupation require extended periods of sitting?

Does your occupation require repetitive movements? (If YES, please explain.) _____________________________________________________________________________

Does your occupation require you to wear shoes with a heel (e.g., dress shoes)?

Does your occupation cause you mental stress?

Recreational Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.) _____________________________________________________________________________

Do you have any additional hobbies (reading, video games, etc.)? (If YES, please explain.) _____________________________________________________________________________

Medical Have you ever had any injuries or chronic pain? (If YES, please explain.) _____________________________________________________________________________

Have you ever had any surgeries? (If YES, please explain.) _____________________________________________________________________________

Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? (If YES, please explain.) _____________________________________________________________________________

Are you currently taking any medication? (If YES, please explain.) _____________________________________________________________________________

Additional Information

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