Par-Q/ Waiver Form PAR-Q and Waiver Name* First Last Date* MM slash DD slash YYYY Email* 1. 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 2. Do you feel pain in your chest when you do physical activity?* YES NO 3. In the past month, have you had chest pain when you were not doing physical activity?* YES NO 4. Do you lose your balance because of dizziness or do you ever lose consciousness?* YES NO 5. 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 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?* YES NO 7. Do you know of ANY OTHER REASON why you should not do physical activity?* YES NO
