Falls Participant Agreement & Par Q Falls Participant Agreement & Par Q Step 1 of 2 50% PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q AND YOU) (This is a self-evaluation. Please keep for your records.) Introduction: Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions below. If you are between the ages of 15 and 69, the PARQ will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not accustomed to being very active, check with your doctor. Directions: Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly, check YES or NO.1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? YES NO 2. Do you feel pain in your chest when you do physical activity? YES NO 3. In the past month, have you had chest pain when you were not doing physical activity? YES NO 4. Do you lose your balance because of dizziness or do you ever lose consciousness? YES NO 5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? YES NO 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? YES NO 7. Do you know of any other reason why you should not do physical activity? YES NO If you answered YES to one or more questions - Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal, tell your doctor about the PAR-Q and which questions you answered YES. ● You may be able to do any activity you want - as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. ● Find out which community programs are safe and helpful for you. If you answered NO to all PAR-Q questions, you can be reasonably sure that you can: ● Start becoming much more physically active-begin slowly and build up gradually. This is the safest and easiest way to go. ● Take part in a fitness appraisal-this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. Delay becoming much more active: ● If you are not feeling well because of a temporary illness such as a cold or a fever-wait until you feel better. Please note: If your health changes so that you then answer YES to any of the questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.Reprinted from the 1994-revised version on the Physical Activity Readiness Questionnaire (PAR-Q and YOU).29 The PAR-Q and YOU is a copyrighted, pre-exercise screen owned by the Canadian Society of Exercise Physiology. Participant Name* I (fill in name above) agree to participate in A Matter of Balance or Tai Chi for Arthritis.I have been informed that the sessions will include light to moderate exercise including stretching, balance and range of motion exercises. I take full responsibility for my participation in these exercises. I agree to work within my own comfort zone and agree to stop exercising if I feel any pain or discomfort and will let one of the facilitators know. I have reviewed the PAR-Q. If indicated, I agree to contact my physician regarding the exercises I will be doing as part of the falls prevention programs.Physician's Advice Because I have answered "yes" on the PAR-Q, I sought the advice of my physician (name below) regarding the falls prevention exercises. Physician's Name I received permission to engage in the exercises. I was advised to take the following precautions: Participant Signature:* Date:* MM slash DD slash YYYY
