Hannah Walker Fitness.
Par Q.

Please complete the Par Q form below.

    Are you currently under a doctor’s care: Yes / No?:
    YesNo

    Do you take any medications on a regular basis? Yes / No?:
    YesNo

    Have you been recently hospitalised? Yes / No?:
    YesNo

    Do you smoke? Yes / No?:
    YesNo

    Are you pregnant? Yes / No?:
    YesNo

    Do you drink alcohol more than three times/week? Yes / No?:
    YesNo

    Is your stress level high? Yes / No?:
    YesNo

    Are you moderately active on most days of the week? Yes / No?:
    YesNo

    Do you have:

    High blood pressure? Yes / No?:
    YesNo

    High cholesterol? Yes / No?:
    YesNo

    Diabetes? Yes / No?:
    YesNo

    Known heart disease? Yes / No?:
    YesNo

    Rheumatic heart disease? Yes / No?:
    YesNo

    A heart murmur? Yes / No?:
    YesNo

    Chest pain with exertion? Yes / No?:
    YesNo

    Irregular heart beat or palpitations? Yes / No?:
    YesNo

    Lightheadedness or do you faint? Yes / No?:
    YesNo

    Unusual shortness of breath? Yes / No?:
    YesNo

    Cramping pains in legs or feet? Yes / No?:
    YesNo

    Emphysema? Yes / No?:
    YesNo

    Other metabolic disorders (thyroid, kidney, etc.)? Yes / No?:
    YesNo

    Epilepsy? Yes / No?:
    YesNo

    Asthma? Yes / No?:
    YesNo

    Back pain: upper, middle, lower? Yes / No?:
    YesNo

    Other joint pain? Yes / No?:
    YesNo

    Muscle pain or an injury? Yes / No?:
    YesNo

    Have your Parents or Siblings who, prior to age 55 had:

    A heart attack? Yes / No?:
    YesNo

    A stroke? Yes / No?:
    YesNo

    High blood pressure? Yes / No?:
    YesNo

    To the best of my knowledge, the above information is true.