健身俱乐部正健康调查问卷(英文).doc

健身问卷
PAR-Q Questionnaire

Yes No

1. Has your doctor ever said that you have a heart condition and recommended you only participate in specific activities?

2. Do you have chest pain brought on by physical activity?

3. Have you developed chest pain in the past month?

4. Do you ever lose consciousness or become dizzy and lose your balance?

5. Do you have a bone or joint problem that could be aggravated by the proposed physical activity?

6. Is your doctor currently prescribing medication for your blood pressure or a heart condition? （e.g. Diuretic or water pills)

7. Are you aware, through your own experience or a doctor's advice, or any other reason why you should not exercise without medical approval?
8. Are you pregnant? （Females only）
“YES” to one or more questions
1. Talk to your doctor before becoming physically active or before you have a fitness evaluation.

Name: Phone:

I have read, understood and completed this questionnaire
signature or if under 18 parent/guardian signature
2. Tell your doctor about the PAR-Q and which questions you answered "yes".
3. 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 to your doctor and follow his/her advice.
NOTE
1. If you have a temporary illness, such as a fever, or are not feeling well at this time, we advise that you postpone the proposed activity.
2. If you are pregnant, you are advised to discuss the "Par-X for Pregnancy" form with your physician before exercising.
If there are any changes in your status relative to the above questions, please bring this information to the attention of the fitness professional. You may need to make adjustments to your program.
In case of emergency, please contact: