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Physical Activity Readiness Questionnaire (Par-Q)

A self-administered questionnaire for adults designed to help you help yourself. Many health benefits are associated with
regular exercise and the completion of a Par-Q is sensible first step to take if you are planning to increase the amount of
physical activity in your life.

YES
NO
  
Has a doctor ever said you have a heart condition and recommended only medically supervised activity?
Do you have chest pain brought on by physical activity?
Have you developed chest pains at rest within the past month?
Do you tend to lose consciousness or lose your balance as a result of dizziness?
Do you have a bone or joint problem that could be aggravated by proposed physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition (diuretics or water pills)?
Are you aware, though your own experience or doctor's advice, of any other physical reason against your exercising without medical approval?

Notes:
1) This questionnaire applies only to those 13-69 years of age.
2) If you have a temporary illness, such as a fever, or are not feeling well at this time, you may wish to postpone the proposed activity.
3) If you are pregnant, you are advised to discuss the “Par-X for Pregnancy” from with your physician before exercising.
4) If there are any changes in your status relative to the above questions, please bring this information to the immediate attention of
    your fitness professional.

I understand that it is advisable to consult with a physician before beginning any physical fitness program. I acknowledge that I
shall at all times, be solely responsible to determine my physical condition and capacity to participate in this course or courses.

I the undersigned, do hereby release and agree to indemnify and save harmless RenewENG and their employees from any and all
claims or causes of action whatsoever arising causing any loss injury or damage to any person or property occurring while being
present at, participating in or travelling to or from the course(s), which I or any person, claiming through me or on my behalf, may
at any time have arising out of or connected with operation of this course.

Program Name Session Dates Day/Time Location Cost
     
Total
     
Payment Type (Cash/Cheque)

Signature:                                                                                                                  Date:
Signature of parent or guardian (for participants under the age of majority)

Refund Policy:

Full refunds are given if RenewENG cancels a class. If an official medical note from a practicing doctor is provided a partial
refund will be issued prorated to the date the medical note was received, minus a $20 service fee .

Please print off two copies of this completed registration from, one for your records and the other to be sent to us.

Toronto (905) 876-2746