HEALTH/MEDICAL QUESTIONNAIRE PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

Transcription

1 WRC Staff Use Only WRC Staff Initials Physician s Clearance received? Yes No N/A Orientation complete? Yes No Health/Medical History form signed? Yes No Assumption of Risk form signed? Yes No PAR-Q signed? Yes No CVD Risk Classification? Low Moderate High HEALTH/MEDICAL QUESTIONNAIRE Name (Please Print) Department College or Unit ο Male ο Female Phone (Home) ( ) (Work) ( ) DOB / / Occupation (circle) A&P Faculty USPS Other E- mail Employee ID Emergency Contact Login ID YES Emergency Contact Phone ( ) PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q) NO Please read the questions below carefully and answer each one honestly: check YES or 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 (for example, back, knee or hip) 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? PLEASE NOTE: If you have answered YES to any of the above questions, please have your physician complete an approval form prior to working out. If your health changes so that you then answer YES to any of the above questions, inform a WRC staff member immediately. Signature Witness

2 For the following questions, please check YES or NO. YES NO Cardiovascular Risk Factors Are you a man 45 years or older? Please indicate any conditions/diseases you have, or have had in the past. Are you a woman 55 years or older? Do you currently smoke cigarettes, or have you quit within the past 6 months? Is your blood pressure greater than 140/90 mm/hg? Do you know your blood pressure? If yes, please specify: / Have you ever been told that your total cholesterol is > 200 mg/dl, or your HDL is < 40 mg/dl or your LDL is > 130 mg/dl? Do you know your cholesterol levels? If yes, please specify: Total HDL LDL Have you had a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister)? Are you physically inactive (i.e., you get <30 min of physical activity on at least 3 days/week)? Are you diabetic or do you take medication to control your blood sugar? Are you more than 20 pounds overweight (BMI 30 kg/m 2 )? Approximate Height Weight BMI Heart Attack Arrhythmia/Heart murmur Stroke Coronary Bypass, Angioplasty, or other cardiac surgery Peripheral Vascular Disease Valvular Heart Disease Congestive Heart Failure Asthma Renal Failure Emphysema Ankle Edema Pneumonia Unusual Shortness of Breath Bronchitis Diabetes Thyroid Disease Hepatitis Ulcer or other Stomach/GI Problems Amenorrhea Bleeding Disorders Chronic Fatigue Syndrome Depression/Emotional Disorders Anemia Hernia Back / Shoulder / Neck Problems (circle) Hip / Knee / Foot Problems (circle) Arthritis / Tendonitis (circle) Broken Bones (describe below)

3 If you checked any of the above diseases or conditions, please provide details: Please list any prescribed medications and dosages you are currently taking. Medication Dose Reason Please list any over-the-counter medications or dietary supplements and doses you are currently taking. Supplement/Medication Dose Reason Please list any hospitalizations or surgical procedures within the last 2 years. Hospitalization/Surgery Reason

4 Are you currently pregnant or have you given birth within the past 6 months? Yes No Are you currently being treated for any other medical condition(s)? Yes No If yes, please specify: Please indicate your fitness/health goals from the following: Improve Aerobic Fitness Yes No Improve Strength Yes No Gain Muscle Yes No Lose Fat Yes No Improve Flexibility Yes No Other I have answered these questions accurately and completely. I understand that my medical history is a very important factor in the development of a fitness/wellness program. Medical or physical conditions which are known to me, but which I do not disclose to the staff may result in serious injury to me. If any of the above conditions change, I will immediately inform a member of WRC staff. I knowingly and willingly assume all risks of injury resulting from my failure to disclose accurate, complete and updated information in accordance with the above questionnaire. Signature

5 Assumption of Risk The Faculty or Staff Member acknowledges that The has informed the Faculty/Staff of increased risk of musculoskeletal injury and cardiopulmonary incidences while exercising. Although exercise induced incidences are low, there remains an inherent risk. The Faculty/Staff acknowledges that the use of exercise at the Center s facilities involves risk of personal injury, including heart attack, and other coronary complications. With this knowledge, the Faculty/Staff assumes all responsibility for all risk of injury that may occur to Faculty/Staff while present in the Center. In consideration of being accepted as a participant of the center, the Faculty/Staff agrees to release and hold harmless The University of Central Florida and their agents, servants, and employees from all claims, liability, demands, rights, and causes of action, present or future, whether known, anticipated, or unanticipated, resulting from or arising out of, or incident to Member s use of, presence at, or membership in the Center. Signature: : Witness: Print Name: :