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NXGen Fitness PAR-Q

The Physical Activity Readiness Questionnaire for Everyone

The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.

If you are planning to become much more physically active than you are now, start by answering the seven questions below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.

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

INFORMED USE of the PAR-Q: P & E Fitness, Inc. dba NXGen Fitness Center and their agents assume no liability for persons who undertake physical activity and if in doubt after completing this questionnaire, consult your doctor prior to physical activity.

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's General Health Questions
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
YES
NO
Do you feel pain in your chest when you do physical activity? *
YES
NO
In the past month, have you had chest pain when you were not doing physical activity? *
YES
NO
Do you lose your balance because of dizziness or do you ever lose consciousness? *
YES
NO
Do you have a bone or joint problem (for example: back, knee or hip) that could be made worse by a change in your physical activity? *
YES
NO
Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure or heart condition? *
YES
NO
Do you know of any other reason why you should not do physical activity? *
YES
NO
First Participant's Signature*
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 session with a trainer. 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 gradually. 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 NXGen Fitness programs are safe and helpful for you.
If you answered NO to all questions...

If you answered NO honestly to all 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 session with a personal trainer. 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 more physically active.

Delay Becoming Much More Active:

  • If you are not feeling well because of a temporary illness such as a cold or fever, wait until you feel better or
  • If you are or may be pregnant, talk to your doctor before you start becoming more 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. This physical activity clearance becomes invalid if your condition changes so that you would answer YES to any of the seven questions and a new one should be completed.

Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's General Health Questions
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
YES
NO
Do you feel pain in your chest when you do physical activity? *
YES
NO
In the past month, have you had chest pain when you were not doing physical activity? *
YES
NO
Do you lose your balance because of dizziness or do you ever lose consciousness? *
YES
NO
Do you have a bone or joint problem (for example: back, knee or hip) that could be made worse by a change in your physical activity? *
YES
NO
Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure or heart condition? *
YES
NO
Do you know of any other reason why you should not do physical activity? *
YES
NO
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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