Pre-Activity Readiness Questionnaire (PARQ) Name * First Name Last Name Date * MM DD YYYY Email * Height (inches) Weight (lbs) Age Physician's Name Phone (###) ### #### Emergency Contact Info: Emergency Contact Name First Name Last Name Relationship Phone (###) ### #### PARQ Questionnaire Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Yes No Do you feel pain in your chest when you perform physical activity? Yes No In the past month, have you had chest pain when you were not performing any 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 that could be made worse by a change in your physical activity? Yes No Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? Yes No Do you know of any other reason why you should not engage in physical activity? Yes No If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. If you answered “No” to all of the above questions, please continue to pages 3 and 4 to complete the short General Occupational, Recreational, and Medical Questionnaire. General Occupational, Recreational, and Medical Questionnaire What is your current occupation? Does your occupation require extended periods of sitting? Yes No Does your occupation require extended periods of repetitive movements? Yes No If yes, please explain. Does your occupation require you to wear shoes with a heel (dress shoes)? Yes No Does your occupation cause you anxiety (mental stress)? Yes No Do you partake in any recreational activities (golf, tennis, skiing, etc.)? Yes No If yes, please explain. Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? Yes No If yes, please explain. Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? Yes No If yes, please explain. Have you ever had any surgeries? Yes No If yes, please explain. Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes? Yes No If yes, please explain. Are you currently taking any medication? Yes No If yes, please list. Personal Training Waiver/Release I have completed the above PARQ and General Medical Questionnaire truthfully and fully. I declare myself and myself only to be responsible for my own health and safety while participating in activities with Frances Kao LLC, The Movement, Frances Kao. My participation in activity with Frances Kao LLC, The Movement, Frances Kao is voluntary and at my own risk. Furthermore, I understand the activities may involve strenuous physical exercise and risk of bodily injury and I accept full responsibility for any activity I engage in with Frances Kao LLC, The Movement, Frances Kao. I hereby release respective owners of Frances Kao LLC, The Movement, Frances Kao, and assigns from any liability for any claims, demands, injuries, actions, or causes of actions to my person or property arising out of, or connected with, the use of any of the services or facilities provided by Frances Kao LLC, The Movement, Frances Kao, now or in the future. NOTE: If you need to cancel an appointment, we do ask for at least 24-hour notice or your late cancellations appointment will be charged the same as a regular session. Also, cancellations for a Monday appointment must be made on the Friday beforehand. The weekend does not count toward the 24-hour buffer to avoid a late cancellation charge. I have carefully read with a full, definite, and clear understanding of the foregoing provisions and freely enter into the agreement of the waiver/release. By typing your name below you are signing this questionnaire Thank you for completing your Pre-Activity Readiness Questionnaire. I look forward to moving with you!
