Physical Readiness Form

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Name

First

Last

Phone

Please read the following questions carefully and check (X) next to the appropriate answers. Answer all questions honestly and to the best of your ability.

1) Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or 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) 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 during 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) BELOW:

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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 your current ability to be physically active. PLEASE LIST CONDITION(S) HERE:

7) Has your doctor ever said that you should only do medically supervised physical activity?

If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION and submit the form. You do not need to complete section 3.

SECTION 3: Follow-up Questions About Your Medical Condition(s)

1) Do you have Arthritis, Osteoporosis, or Back Problems?

If the above condition(s) is/are present, answer question 1a-1c. If you answered 'NO' go to question 2.

1a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

(Answer NO if you are not currently taking medications or other treatments)

1b) Do you have joint problems causing pain,a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)

1c) Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

2) Do you currently have Cancer of any kind?

If the above condition(s) is/are present, answer questions 2a-2b. If you answered 'NO' go to question 3.

2a) Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?

2b) Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?

3) Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm

If the above condition(s) is/are present, answer questions 3a-3d. If you answered 'NO' go to question 4.

3a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

(Answer NO if you are not currently taking medications or other treatments)

3b) Do you have an irregular heartbeat that requires medical management?

(e.g., atrial fibrillation, premature ventricular contraction)

3c) Do you have chronic heart failure?

3d) Do you have diagnosed coronary artery (cardiovascular)disease and have not participated in regular physical activity in the last 2 months?

4) Do you currently have High Blood Pressure?

If the above condition(s) is/are present, answer questions 4a-4b If you answered 'NO' go to question 4.

4a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

(Answer NO if you are not currently taking medications or other treatments)

4b) Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?

(Answer YES if you do not know your resting blood pressure)

5) Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes

If the above condition(s) is/are present, answer questions 5a-5e If you answered 'NO' go to question 6.

5a) Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?

5b) Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or duringactivities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.

5c) Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affectingyour eyes, kidneys, OR the sensation in your toes and feet?

5d) Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?

5e) Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

6) Do you have any Mental Health Problems or Learning Difficulties?

This includes Alzheimer's, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome.
If the above condition(s) is/are present, answer questions 6a-6b. If No go to question 7.

6a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

(Answer NO if you are not currently taking medications or other treatments)

6b) Do you have Down Syndrome AND back problems affecting nerves or muscles?

7) Do you have a Respiratory Disease?

This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure. If the condition(s) is/are present, answer questions 7a-7d
If NO to question 8

7a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

(Answer NO if you are not currently taking medications or other treatments)

7b) Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

7c) If asthmatic,do you currently have symptoms of chesttightness,wheezing,labouredbreathing,consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

7d) Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

8) Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia

If the above condition(s) is/are present, answer questions 8a-8c If NO go to question 9

8a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

(Answer NO if you are not currently taking medications or other treatments)

8b) Do you commonly exhibit low resting blood pressure significant enoughto cause dizziness, light-headedness, and/or fainting?

8c) Has your physician indicated that you exhibit suddenbouts of high blood pressure (known as Autonomic Dysreflexia)?

9) Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event

If the above condition(s) is/are present, answer questions 9a-9c If NO go to question 10

9a) Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

(Answer NO if you are not currently taking medications or other treatments)

9b) Do you have any impairment in walking or mobility?

9c) Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

10) Do you have any other medical condition not listed above or do you have two or more medical conditions?

If the above condition(s) is/are present, answer questions 10a-10c If NO go to PARTICIPANT DECLARATION

10a) Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?

10b) Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?

10c) Do you currently live with two or more medical conditions?

PARQ+

SECTION 3: Follow-up Questions About Your Medical Condition(s)

PARTICIPANT DECLARATION

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