UNIVERSITY OF SANTO TOMAS

INSTITUTE OF PHYSICAL EDUCATION AND ATHLETICS

SERVICE PHYSICAL EDUCATION DEPARTMENT

Students Name: LINAY, MARIA JENNYLYN College/ Sec.: 1HR1

The Philippine Physical Activity Readiness Questionnaire (PPAR-Q) modified by Bernardo

Bonoan (2006) is a self-guided question-screening tool that is able to quickly identify
conditions or risk factors that require further assessment before commencing exercise. This
questionnaire is adapted from the British Columbia Ministry of Health and the Multidisciplinary
Board on Exercise.

PHILIPPINE PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PPAR-Q)

(Bonoan, Bernardo 2006)

Please read the questions carefully and answer (/) each one honestly.
Basahin nang mabuti ang mga tanong at sagutin (/) nang buong katapatan.

YES No Questions
(Oo) (Hindi) (Tanong)
/ Has your doctor ever diagnosed you to have a heart condition and that you should only
do physical activity recommended by a doctor?
(Sinabihan ka na ba ng doktor mo na ikaw ay may karamdaman sa puso at ang dapat
mo lang gawing pisikal ay ang rekomendado ng doktor?)
/ Is your doctor currently prescribing drugs for your blood pressure or heart condition?

(Kasalukuyan ka bang umiinom ng gamot na inireseta ng doktor mo para sa mataas na

presyon ng dugo o karamdaman sa puso?)
/ Do you experience pain or discomfort in the chest, neck, and jaw area during mild
physical activity or at rest?
(Nakakaramdam ka ba ng sakit o karamdaman sa dibdib, leeg, o gawing panga
habang gumagawa ng malumanay na gawaing pisikal o kaya ay nagpapahinga?)

/ Do you experience shortness of breath with mild physical exertion?

(Nakakaramdam ka ba ng kahirapan sa paghinga habang gumagawa ng malumanay
na gawaing pisikal?)
/ Do you get tired frequently even when not doing physical activity or are you frequently
drowsy?
(Madalas ka bang napapagod maski na walang ginagawang pisikal o madalas ka bang
nananamlay?)
/ Have you lost weight rapidly recently with or without feelings of extreme hunger?
(Namayat o nawalan ka ba ng timbang nang sobrang bilis kamakailan nang hindi
nakakaramdam ng matinding gutom?)
/ Do you have a bone or joint pain that increases with movement? Is there a sudden
increase in pain when bending or touching the joint?
(Nakakaramdam ka ba ng sakit sa buto o kasu-kasuan na lumalala kapag gumalaw?
May biglang pagtindi ba ng sakit kung binabaluktot o hinahawakan ang kasu-kasuan?)
/ Do you know of any other reason why you should not do physical activity?
(Meron ka bang alam na iba pang dahilan kung bakit hindi ka dapat gumawa ng kahit
ano mang gawaing pisikal?)

If you answered YES to any question, please see an EIM certified specialist. Thank you.
(Kapag may sinagutan ka ng Oo, maaari lang magpakita sa EIM certified specialist. Salamat.)

UST-IPEA A.Y. 2021-2022

 UNIVERSITY OF SANTO TOMAS
INSTITUTE OF PHYSICAL EDUCATION AND ATHLETICS
SERVICE PHYSICAL EDUCATION DEPARTMENT

I hereby confirm that the information given in this form is true and correct to the best of
my knowledge and belief.

Signature of Parents/ Guardian: ____________________________Date: August 14, 2021

In case of emergency:

Parents/ Guardian Name: Angela A. Linay Relation: Mother

Home Address: Unit 26 Lot 1 Block 1 Seminary Road Edsa Barangay Bahay Toro, Quezon
City

Contact No.: 0932 963 1638 Email Address: angallinay@gmail.com

*Only Registered Physicians or Specialists will fill up the questions below.

Clearance Recommendations: Please put a mark ( / or x) inside the box.

He/She is cleared to participate in unrestricted activity.

He/She is cleared to participate in light to moderate activity only.

He/She should not participate in activity at this time pending further evaluation.

Others: Please specify: _______________________________________________________

__________________________________________________________________________

Signature of Physician:_____________________________________Date:_____________

*Please attach medical records or certificates if found with any medical conditions upon
submission of this form.

UST-IPEA A.Y. 2021-2022

 UNIVERSITY OF SANTO TOMAS
INSTITUTE OF PHYSICAL EDUCATION AND ATHLETICS
SERVICE PHYSICAL EDUCATION DEPARTMENT

STUDENT AND TEACHER CONSENT AND RELEASE FORM

To comply with the Data Privacy Act of 2012 (DPA) and cooperate fully with the National Privacy
Commission (NPC) and the data privacy policy of the University of Santo Tomas, all personal
information, data, outputs gathered in this subject will be solely used in monitoring and supporting the
students’ progress and with this, all personal data and information gathered here will be respected and
confidentiality kept and will not be shared, posted, published, saved or transferred outside of our
course.

However, all submitted materials and output will be used as benchmark material to help in the
academic development of this subject.

Likewise, All instructional materials, such as slide presentation, handouts, documents, videos, session
recordings, worksheets and links uploaded in our course site are copyrighted works and must not be
shared, posted, published, saved or transferred outside without the full knowledge and consent of your
professor. These materials are solely researched, compiled, and developed for you as part of your
benefits and privileges as an enrolled student of the University. This is to respect and uphold
copyright.

I have read and fully understand the terms of this consent and release form without expectation of
compensation or other remuneration, now or in the future, I hereby give my consent to Kirby Matthew
F. Ong, LPT IPEA- Service PE Professor, to use my submitted output as a sample learning materials
and permission to mention my name in her classes.

Student Name: LINAY, MARIA JENNYLYN A. Signature: _____________Date: August 14, 2021

College / Institution: College of Commerce BA Human Resource Management Section: 1HR1

Professors Name: Alexander Leano LPT MAed IPEA Service Professor

Signature: _____________Date:__________

The below signed parent or legal guardian of the above-named minor child hereby consents to and
gives permission to the above on behalf of such minor child.

Parent’s Name / Legal Guardian: Angela A. Linay

Address: Unit 26 Lot 1 Block 1 Seminary Road Edsa Quezon City

Signature: _________________________________________ Date: August 14, 2021

Should you have questions or concerns regarding this agreement, please talk to your
professor for clarifications.

UST-IPEA A.Y. 2021-2022