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Physical Activity Readiness Questionnaire

Awaken Your Purpose

Email: rj@awakenyourpurposetoday.com

Phone: (919) 322-8030

Physical Activity Readiness Questionnaire

Regular physical activity is fun and healthy for most people; however, all participants should check with their doctor before starting an exercise program. If you are planning to use AWAKEN YOUR PURPOSE (RJ Perkins), you must answer the seven questions below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you are required to check with your doctor and obtain a Physician’s Medical Release Form before you start. If you are over 69 years of age, you are required to check with your doctor and obtain a Physician’s Medical Release Form prior to using AWAKEN YOUR PURPOSE (RJ Perkins). Common sense is your best guide when you answer these questions. Please read each question carefully and answer each one honestly.

Has your doctor ever said you have a heart condition and recommended only medical supervised physical activity?
Yes
No
Do you have chest pain brought on by physical activity?
Yes
No
Have you developed chest pain within the past month?
Yes
No
Do you tend to lose consciousness or fall over as a result of dizziness?
Yes
No
Do have a bone or joint problem that could be aggravated by the proposed physical activity?
Yes
No
Has a doctor ever recommended medication for your blood pressure or a heart condition?
Yes
No
Are you aware, through your own experience or a doctor’s advice, of any other physical reason against you exercising without medical supervision?
Yes
No

If you answered YES to any of the above questions or are over the age of 69:


Consult with your physician in person or by phone BEFORE you start to become more physically active or BEFORE you have a fitness appraisal. Advise your physician of the PAR-Q and the answers in which you answered YES.


• You may be able to do any activity you would like – if 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 physician 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.


• Based on what you have answered YES to you may be required by Awaken Your Purpose (RJ Perkins) to obtain a Physician’s Medical Release Form prior to using the services of Awaken Your Purpose (RJ Perkins).

If you answered NO honestly to all of the above 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.

Delay becoming much more active:


• If you are not feeling well because of a temporary illness such as cold or fever—wait until you feel better.


• If you are or may become pregnant, talk to your doctor and receive a Physician’s Medical Release Form prior to utilizing AWAKEN YOUR PURPOSE (RJ Perkins).

Please Note: If your health changes so that you then answer YES to any of the above questions, your age exceeds 69, or you become pregnant, you are responsible for informing AWAKEN YOUR PURPOSE (RJ Perkins) and will be required to obtain a Physician’s Medical Release form.

I have read, understand, agree, and completed this questionnaire honestly and to the best of my knowledge.

Client/Parent/Guardian's Signature*

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Confidential Document

Provided information is to be used by Awaken Your Purpose (RJ Perkins) only and is a protected confidential file.

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