Insert recent

Physical Activity Readiness Questionnaire (PAR-Q) photo here

Leo Christian Anthony A. Burlat

Name: ________________________________________ Age: 18
____ BS Accy 1
Section: _________________
Engaging in physical activity is healthy and enjoyable. For MOST people, doing vigorous to moderate physical activity is very safe.
However, for some people need to consult with their doctor before becoming physically active.
Since you will engage in physical activity for this physical education course, this questionnaire will tell you whether it is necessary
for you to seek further advice from your doctor OR a qualified exercise professional before participating in class.

GENERAL HEALTH QUESTIONS

Please read the 7 questions below carefully and answer each one honestly: check YES or NO YES NO
1. Has your doctor ever said that you have a heart condition  OR  high blood pressure?
 
2. Do you feel pain in your chest at rest during your daily activities of living, OR when you do
physical activity?  
3. Do you lose balance because of dizziness OR have you lost consciousness in the last 12
months? Please answer NO if your dizziness was associated with over-breathing (including vigorous exercise).  
4. Have you ever been diagnosed with another chronic medical condition (other than heart disease
or high blood pressure)? PLEASE LIST CONDITION(S) HERE: __________________________________________  
5. Are you currently taking prescribed medications for a chronic medical condition? PLEASE LIST
CONDITION(S) AND MEDICATIONS HERE: __________________________________________  
6. Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue
(muscle, ligament, or tendon) problem that could be made worse by becoming more physically  
active? Please answer NO if you had a problem in the past, but it does not limit our current ability to be physically
active.
PLEASE LIST CONDITION(S) HERE: __________________________________________
7. Do you know any other reason why you should not do physical activity? PLEASE LIST CONDITION(S)
HERE: __________________________________________  
IF YOU answered YES to one or more questions IF YOU answered NO to all of the questions above, you are cleared for
physical activity.
Talk with your PE instructor in person BEFORE you start becoming more
physically active and/or participating in Physical Education activities. Tell You can start becoming more physically active.
your instructor about the PAR-Q and which questions you answered YES. You can participate in all of the physical activities set by the PE
course.
 You may be able to do any physical activity you want-as long  You can may take part in a health and fitness testing
as you start slowly and buildup gradually  Please sign the PARTICIPANT DECLARATION.
 For PE related activities, your instructor may give you alternate PARTICIPANT DECLARATION.
physical activities which is safe for you OR may refer you to talk
to your doctor for advice regarding the physical activities that If you are less than the legal age required for consent or require the assent
are safe for you. of a care provider, your parent, guardian or care provider must also sign
this form.

I, the undersigned, have read to my full satisfaction and completed this

DELAY becoming much more active: questionnaire. I acknowledge that this physical activity clearance is valid
for the 1st
___ semester, SY ____-_____
2024 2025 and becomes invalid if my condition
o If you are not feeling well because of a temporary illness such changes. I also acknowledge that the CMU Physical Education
as cold or a fever – wait until you fell better Department may retain a copy of this form for its records. In these
o If you are or may be pregnant – talk with your doctor before you instances, it will maintain the confidentiality of the same, complying with
start becoming more active. Convey this information to your PE the Data Privacy Act of 2012.
instructor by personally talking to them and presenting a
medical certificate. Signature over Printed Name:

LEO CHRISTIAN ANTHONY A. BURLAT Date: 09/01/2024

___________________________________________ _______
PLEASE NOTE: If your health changes so that you then answer
YES to any of the above questions, tell your PE instructor. Ask Signature over Printed Name of PARENT/GUARDIAN:
whether you should change your physical activity plan. ARLENE A. BURLAT
___________________________________________ Date: 09/01/2024
_______

Central Mindanao University- Physical Education Department 2024

Informed use of the PAR-Q. Adapted from: Physical Activity Readiness Questionnaire for Everyone (PAR-Q+), 2022 PAR-Q+ collaboration and ACSM’s Health/Fitness Facility Standards and Guidelines,
1997 by American College of Sports Medicine