PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

Sports acceleration is very safe for most athletes. However, some athletes should check with their doctor before they start our program.

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly:  choose  YES  or  NO.

YES     NO     1. Has a doctor ever said you have a heart condition and recommended only medically supervised physical activity?
YES     NO     2. Do you have chest pain brought on by physical activity?
YES     NO     3. Have you developed chest pain within the past month?
YES     NO     4. Do you tend to lose consciousness or fall over as a result of dizziness?
YES     NO     5. Do you have a bone or joint problem that could be aggravated by the program?
YES     NO     6. Has a doctor ever recommended medication for your blood pressure or a heart condition?
YES     NO     7. Are you aware, through your own experience or a doctor's advice, of any other physical reason which should limit or prevent you from exercising without medical supervision?

If you answered yes to one or more of the previous questions, exercise testing and acceleration participation should be postponed and medical clearance should be sought. Talk with your doctor by phone or in person BEFORE you start the program. Tell your doctor about this survey and which questions you answered YES.

I have read, understood and completed this questionnaire. All questions were answered to my full satisfaction.

Medical History

Smoking (within the last year) Yes     No    
High Blood Pressure (> 140/90) Yes     No    
History of Heart Disease (personal) Yes     No    
History of Heart Disease (family) Yes     No    
Diabetes (personal) Yes     No    
Diabetes (family) Yes     No    
Elevated Cholesterol (> 240 mg/dl) Yes     No    
Heart Murmur Yes     No    
Arrhythmia Yes     No    
Pain or discomfort in chest Yes     No    

Have you ever had difficulty breathing?     Yes     No    
If so, please explain:

Have you ever experienced fainting or dizzy spells?     Yes     No    
If so, please explain:

Have you been injured recently?     Yes     No    
If so, please explain:

Are you currently taking any medication?     Yes     No    
If so, please explain:

Is there any condition that might limit your participation in an exercise program?     Yes     No    
If so, please explain:


School:

Team:     Coach:  

What sports will you be training for?

What position or event?

What are your goals in your sport? (Please be as specific as possible)

Are you currently exercising?     Yes     No    
If so, please explain:

When does your sport season begin?

What days will you be able to train with us? (please check all that aply)
M       T       W       Th       F       Sat.      


I have read, understood, and completed this questionnaire. All questions were answered to my full satisfaction.

Name:     
                              First                                     Middle                                   Last

Address:       
                        Street or PO Box                     City             State     Zip Code


Date of Birth: XX/XX/XXXX       Height:     Weight:     Gender (M/F):   
Home Phone: Work Phone:
E-Mail: SSN:  XXX-XX-XXXX
Physician:     Primary Hospital:

Parent or Guardian Name:


Signed:_____________________       Date _____/_____/_____
                      Participant

     _____________________(Parent of Guardian, if athlete is under 18)


HEART OF AMERICA SPORTS MEDICINE INFORMED CONSENT

PLEASE READ the accompanying information regarding fitness evaluation, acceleration protocols, and equipment usage. If you have any questions please ask the HAMC Sports Medicine Staff.

  1. I HEREBY CONSENT TO and PERMIT the Heart of America Sports Medicine Staff to use testing data obtained in report or publications.
    my identity will not be associated with such reports.
    my identity will be associated with such reports.

  2. My participation is voluntary and I may withdraw from the evaluation or program at any time.

  3. All testing and training will be under the direction of the HAMC Sports Medicine Staff.

  4. I understand that my participation in Acceleration testing and protocols should not result in physical injury to me, however, I acknowledge the following:

    In the event of physical injury resulting from my participation in any part of testing or training, or equipment usage, while training with Heart of America Sports Medicine, no medical treatment or monetary compensation will be provided by Heart of America Sports Medicine. I must look to my own health insurance policies to cover any cost related to such an injury.


____________________________
          Signature of Participant

____________________________
                       Date


I acknowledge that the participant is under the age of 18.  I have reviewed the information provided and certify it to be true and correct.

I consent to _______________________ participating in Acceleration evaluations, tests, and protocols.

____________________________
      Parent or Guardian's Signature

After printing this form, please sign the underlined areas.