PAR-Q+ Health Screening

The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+)

2023 PAR-Q+ Collaboration

About the PAR-Q+

The PAR-Q+ is a screening tool designed to identify individuals who may need additional medical clearance before beginning a physical activity program. It is used worldwide and is recognized as the standard pre-participation health screening questionnaire.

At Refinery Strength Collective, we use this form to ensure your training program is safe, effective, and tailored to your unique health needs — especially if you are navigating autoimmune conditions, life transitions, or returning to exercise after time away.

GENERAL HEALTH QUESTIONS

Please read each question carefully and answer YES or NO honestly.

If you answered NO to all of the questions above:

You are cleared for physical activity. Please sign the PARTICIPANT DECLARATION below. You do not need to complete Pages 2 and 3.

Start becoming much more physically active — begin slowly and build up gradually. Follow United States's Physical Activity Guidelines and/or international physical activity guidelines for your age.

You may take part in a health and fitness appraisal and can begin your training program with Amy.

If you answered YES to one or more of the questions above:

Please complete the follow-up questions on Pages 2 and 3 of the PAR-Q+ form. You may still be able to participate in physical activity, but additional screening is recommended.

Amy will work with you and, if needed, your healthcare provider to create a safe and effective training plan.

Follow-Up Questions — For Those Who Answered YES

Please answer the following questions about your specific health condition(s).

Question 1: Heart Condition / High Blood Pressure

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)

☐ YES    ☐ NO

1b. Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction)

☐ YES    ☐ NO

1c. Do you have chronic heart failure?

☐ YES    ☐ NO

1d. Has your doctor told you that you have been diagnosed with coronary artery (cardiovascular) disease and have you had a cardiac procedure (angioplasty or surgery)?

☐ YES    ☐ NO

Question 2: Chest Pain

2a. Do you currently have chest pain during physical activity or at rest that has not been diagnosed?

☐ YES    ☐ NO

Question 3: Dizziness / Loss of Consciousness

3a. Do you currently have a diagnosis of or are being treated for epilepsy, or other seizure conditions?

☐ YES    ☐ NO

3b. Do you currently have problems with recurring dizziness?

☐ YES    ☐ NO

Question 4: Other Chronic Medical Conditions

4a. Have you been diagnosed with or are you being treated for any of the following? (Check all that apply)

☐ Diabetes (Type 1 or Type 2)
☐ Autoimmune condition (e.g., Hashimoto's, Lupus, Rheumatoid Arthritis)
☐ Cancer of any kind
☐ Osteoporosis
☐ Mental health condition (e.g., anxiety, depression)
☐ Respiratory condition (e.g., asthma, COPD)
☐ Spinal cord injury
☐ Stroke
☐ Other chronic condition: _______________

Question 5: Prescribed Medications

5a. Please list your current medications and the conditions they are prescribed for:

Question 6: Bone, Joint, or Soft Tissue Problem

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

☐ YES    ☐ NO

6b. Do you have joint problems causing pain, a+recent fracture, or fracture caused by osteoporosis or cancer, displaced vertebra, and/or spondylolysis/pars defect?

☐ YES    ☐ NO

6c. Have you had a steroid injection or taken steroid tablets regularly for more than 3 months?

☐ YES    ☐ NO

Question 7: Medically Supervised Activity

7a. Has your doctor told you that you should only do medically supervised physical activity? If so, please provide details:

Participant Declaration & Signature

Declaration

All persons who have completed the PAR-Q+ please read and sign the declaration below.

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian, or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that a community/fitness center may retain a copy of this form for their records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

For more information about the PAR-Q+, please visit www.eparmedx.com

© 2023 PAR-Q+ Collaboration. Used with permission.