Par-q

Attachment G1:

American College of Sports Medicine (ACSM) Physical Activity Readiness Questionnaire (PAR-Q)

Form Approved

OMB No. 0920-XXXX

Exp. Date: xx/xx/20xx

Physical Activity Readiness Questionnaire (PAR-Q)

Yes No

□ □ 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

□ □ 2. Do you feel pain in your chest when you do physical activity?

□ □ 3. In the past month, have you had chest pain when you were not doing physical activity?

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

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

□ □ 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

□ □ 7. Do you know of any other reason why you should not do physical activity?

A response of “yes” to any of these screening questions will trigger a physician evaluation of exercise program readiness.

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).