Par-Q/Medical Questionnaire

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Par-Q/Medical Questionnaire

Welcome to the Freedom Aquatic & Fitness Center Exercise is Medicine program. We are committed to ensuring you have safe and effective exercise guidelines so that you may successfully attain your personal health, wellness, and fitness goals. Our fitness assessment and questionnaires are designed to gather objective and subjective information, as well as physical capabilities, health status, and current level of fitness. The outcome of your assessment will be used to help you apply correct exercise adherence, and to avoid exercise that could lead to discomfort or injury. Fitness assessments are not designed to diagnose any condition or to replace a medical examination. You may partake in the full assessment or opt-out of any testing you choose.

The PAR-Q and Medical Questionnaire sheet must be filled out prior to any exercise.
Please have all sheets completed and submitted to the EIM team prior to your first appointment.

PAR-Q: This sheet is primarily aimed at identifying individuals who require further medical evaluation before being allowed to exercise because they are at a high risk for cardiovascular disease. Your health care provider has already referred you to the EIM program, however, should the EIM team determine any additional complications that may require additional clearance, we will ask that you submit to health care provider prior to program start.
MEDICAL QUESTIONNAIRES: Collective information regarding general health, medical history, medications and limitations. This information is crucial to ensuring a safe, enjoyable and productive exercise experience.

GUIDLINES FOR FITNESS ASSESSMENT:

Come dressed appropriately in fitness attire which includes footwear, no open toed shoes or sandals.
Avoid drinking caffeinated or alcoholic beverages, smoking or consuming a heavy meal for at least two hours prior to your appointment. These actions may alter resting and exercising heart rates and responses. (INBODY testing will have a specific per testing criteria)
Do not exercise prior to your assessment.

WHAT TO EXPECT:

Review of General Health and Medical History, including professional and daily routines, to get a better understanding of movement patterns and typical daily energy expenditure.
InBody body composition testing (per test criteria provided)
Physiological measurements: weight, height, measurement assessments.
Cardiorespiratory testing: To determine appropriate starting training zone, HR ranges
Static posture overview: To determine any posture distortion
Dynamic posture: To determine muscle imbalances in dynamic movement patterns

Name:

Date:

Phone:

Email:

Birthdate:

Physician's Name:

Phone:

Gender:

Ethnicity:

Race:

Household Income Level:

How did you hear about the EIM Program?

MEDICAL QUESTIONNAIRE

1. Do you currently experience or have any of the following:

Shortness of breath with activity or at rest?

Difficulty breathing at night, except in an upright position?

Swelling in the ankles or lower extremities (other than due to an injury)?

Heart palpitations (rapid or irregular heartbeat of the heart)?

Pain in the legs that may cause you to stop walking?

Known heart murmur?

2. Are you pregnant or is it likely that you may become pregnant at this time?

If you are pregnant, what is your expected due date?

3. Have you had surgery in the past six months?

If yes, please list the date and nature of the surgery:

4. In the past 12 months, have you been told by a healthcare professional that you have elevated cholesterol or abnormal lipid profile, or are you on any medications to control your blood lipids?

5. Do you currently smoke cigarettes?

6. Have you previously smoked cigarettes, or have you quit within the past six months?

7. Have your father or brother(s) had heart disease prior to the age of 55 or mother or sister(s) had heart disease prior to age 65?

8. Within the past 12 months, have you been told by a healthcare professional that you have an elevated fasting blood glucose level? (>100 mg/dl)

9. Are you currently under the care of a healthcare professional for blood clots or other circulatory problems?

10. Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?

11. Do you currently experience any back and/or neck discomfort or problems?

12. Are you currently under the care of a healthcare professional for any other health/medical problems?

If you have answered YES to any of the medical history questions, please provide any additional information:

Please list below all prescription and over-the-counter medications you are currently taking:

Medication

Dosage

Frequency

Purpose

Are there any medications that your physician and/or healthcare professional have prescribed for you in the past 12 months that you are currently not taking?

If yes, please list:

Are you currently taking any vitamins or supplements? If yes, please list:

Within the past 3 years, has your doctor diagnosed or treated you for any of the following problems?

Neck Problems

Shoulder Problems

Back Problems

Hip Problems (Including Fracture, Replacement)

Knee Problems

Joint Problems

Arthritis

If yes, please specify location:

Asthma

Cancer

Chronic Obstructive Pulmonary Disease (COPD)

Congestive Heart Failure

Diabetes

Emphysema

Epilepsy/seizures

Heart attack or other heart problem

High blood pressure/Hypertension

High Cholesterol

Low blood pressure

Multiple Sclerosis (MS)

Osteoporosis (brittle bones)

Parkinson’s Disease

Peripheral neuropathy (Including loss of feeling in feet or hands)

Stroke

Thyroid problems

Other:

PHYSICAL ACTIVITY RISK STRATIFICATION

The information below will guide to determine risk factors, and necessary levels of monitoring to ensure safe and effective exercise prescription.

Do you currently participate in regular exercise?
(structured physical activity for at least 30 minutes 3x per week for the last 3 months)

If yes, please designate at what level:

Current Weight?

Do you have cardiovascular disease including but not limited to coronary heart disease,
hypertension, arrhythmia (A-fib), or peripheral artery disease?

Do you currently have, or have you ever had a heart attack (myocardial infarction),
stroke, CHF (congestive heart failure) or a congenital heart disease?

Do you have any of the following:
(Three or more indicates metabolic syndrome, and an increased risk for metabolic or cardiovascular disease)

Abdominal obesity as indicated by a waist circumference of >40” for men, or >35” for women

Triglyceride levels >150 mg/dl

HDL levels of <40 mg/dl for men, or <50 mg/dl for women

Blood pressure >130/85

Fasting glucose >100 mg/dl

At rest, or during activity do you have, or have had
in the past 12 months experienced any of the following:

Pain or discomfort in the chest, neck, jaw, arms, or other areas that may result from ischemia

Shortness of breath at rest or during mild exertion

Dizziness or syncope

Ankle or feet edema

Palpitations or tachycardia, and/or a racing, pounding or fluttering heart

Intermittent claudication or leg pain

Heart murmur

Unusual fatigue or shortness of breath while performing normal activity

Has your health care provider ever stated that you need medically supervised physical activity?

Have you had a physical in the last 12 months? If so, please designate date.

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