Youth Health Questionnaire (PAR-Q)
Personal Details:
Name:
Emily
Phone #: 519- 753- 1783
Do you have any of the following? (Check appropriate box(es))
o
o
o
o
o
Asthma
Diabetes
Heart Problems
Joint Problems
Allergies
Have you recently been admitted to a hospital?
o
o
Yes
No
If “Yes”, please specify when and for what reason.
I went to the Mc Masters Children Hospital around 3 weeks ago
I have an upcoming Spinal Fusion surgery and I had to do some x-rays and blood work done.
What do you normally do during break time at school? (Check appropriate box(es))
o
o
o
o
o
Play sport/game
Use library
Eat food
Talk to friends
Other (please specify)
How many hours a day do you spend on your cell phone?
o
o
o
o
Less than 1 hour
1-2 hours
3-4 hours
More than 5 hours
How many hours a day do you play computer/video games?
o
o
o
o
Less than 1 hour
1-2 hours
3-4 hours
More than 5 hours
Are you active outside of school, either with your friends or a team?
o
Yes, with friends
o
o
Yes, with a team
No
PAR-Q Form: Please mark YES or No to the following:
YES

Has your doctor ever said that you have a heart condition and recommended
only medically supervised physical activity?

Do you frequently have pains in your chest when you perform physical activity? NO

Have you had chest pain when you were not doing physical activity?



Have you had a stroke?

Do you have a bone, joint or any other health problem that causes you pain or
limitations that must be addressed when developing an exercise program.
(diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia,
Bulimia, epilepsy, respiratory ailments, back problems, etc…)
NO
NO
NO
NO
Do you lose your balance due to dizziness or do you ever lose consciousness?

Are you pregnant now or have given birth within the last 6 months?

Do you have asthma or exercise induced asthma?

Do you have low blood sugar levels (hypoglycemia)?

Do you have diabetes

Have you had a recent surgery? NO
NO
YES
NO
NO
NO
NO
If you have marked “YES” to any of the above, please elaborate below”
I have scoliosis of a curvature of 79 degrees. My doctor told me since I have my upcoming
surgery somewhere in May, he wants me to be careful of some of the activities I am doing. No
dancing or gymnastics and some sports. He also said I can do some exercises for physed but if
my back starts to hurt, I have to take a break.

Do you take any medication, either prescription or non-prescription, on a regular basis?
What is the medication for?
I don’t take any prescriptions
How does this medication affect your ability to exercise or achieve your fitness goal(s)?
Please read the items below and initial beside them.
1. Any medical concerns pertaining to my fitness training have been discussed with my health
professional (physician, physiotherapist, etc...) and I have been cleared to participate in
exercise. Yes- in some exercises.
2. I understand that strength, flexibility and aerobic exercise including the use of equipment, are
potentially hazardous activities. I am voluntarily participating in these activities.
Yes- in some exercises.
3. I understand that my teacher may provide me with information pertaining to diet and nutrition.
This is for my information only, and not nutrition prescription. I understand that should I require
specific nutritional advice, I will enlist the services of a registered dietician or nutritionist.
Yes
Please note: If your health changes such that you could then answer “YES” to any of the
above questions, tell your trainer/teacher. Ask whether you should change your physical
activity plan.
I have read, understood, and completed the questionnaire. Any questions I had were
answered to my full satisfaction. Yes.
Parent Name:
Parent Signature:
Date:
Student Signature:
Date: