Ac ity No. 3 2015 PARQ+ Hoeger, WWW. Hoeger, S.A. Hoeger C1. & Fawson AL. (2018) Prineples and Labs for Fitness & Wellness Foureenth elton Cengage Leaning, Boston, If you answered NO to all of the follow up questions about your medical condition, you are ready to become more physically active-sign the participant declaration below: It is advised that you consulted 2 qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs. You are encouraged to start slowly and build up gradually-20-60 minutes of low to moderate intens! ‘exercise, 35 days per week including aerobic and muscle strengthening exercises As you progress. You should aim to accumulate 150 minutes or more of moxlerate intensity physical activity per week: If you are over the age of 45 years, and NOT accustomed to regular vigorous to maximal effort exercise, consulta qualified exercise professional before engaging in this intensity of exercise. If you answered YES to one or more of the follow-up questions about your medical condition: You should seek further information before becoming more physically active or engaging in a fitness appraisal. You should complete the specially designed online screening and exercise recommendations program- the ePARMment-X+ at www.eparmedx.com and /or visit a qualified exercise profe sional to work through the ePARment-X and for further information. Delay becoming more active if: Vv Vv You have a temporary illness such as a cold or fever; itis best to wait until you feel better. You are pregnant- talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARment-X+ at www.eparmedx.com before becoming more physically active. Your health changes-talk to your doctor or a qua continuing with any physical activity program. ified exercise professional before ‘You are encouraged to photocopy the PAR-Q+- You must use the entire questionnaire and NO changes are pemmitted ‘The authors, the PAR-Q+ Collaboration, partner organization, and their agents assume no liability to persons who undertake physical activity and/or make use of the PAR-Q+ or ePARMent-X+, [fin doubt after completing the questionnaire, consult your doetor prior to physical activity PARTICIPANT 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. 1, the undersigned, have read, understood 10 my full satisfaction and completed this questionnaire. | acknowledge that this physical activity clearance ts valid for a minimum of 12 months from the date it ts completed and becomes invalid if my condition changes. I also acknowledge that a Trustee (such as my employer: communityflsness centre ‘health care provider, or other designate) may retain a copy of this form for their records. In these instances, the Trustee will be required to adhere to local, national, and international guidelines regarding the storage of personal ‘health information ensuring that the Trustee maintains the privacy of the information and does misuse or wrongfully disclose such information. NAME. SIGNATURE: SIGNATURE OF Pal Emny Rose E. Calimpons pare:_10/10/21 E. Manginsay ENT/GUARDIANICARE PROVIDER2015 PARQ+ FOLLOW-UP QUESTIONS ABOUT YOU ‘or Back Problems? MEDICAL CONDITION(S) Ihe above condo) ire prea anes queines tile. 1tNO gL vesion 2 4a, Do you have difficulty controlling your condition with medications or ether physician-prescribed therapies 1h.Do you have joint problems causing pain a recent fracture or facture caused by osteoporosis or cancer, displaced vertebra (ex spondylolsthesis) and/or spondylosispars defect (aerack in the bony ring on the tuck of the spinal column)? yes Do te Have you had steroid injections or taken steroid tablets regularly for more than 3 mons? ves Do 2. Do you have Cancer of any kind? If the above condition(s) isare present, answer question 22-26. NO sLyAquestion 3 2a, Does your eancer diagnosis include any of the following types langforonchogene, multiple myeloma ‘cancer of plasma cells) head, and neck? ves Co o8 ieecivng cee ety Gach ms cheney of aloo) Ts Ce Th Are you cu {4 Doyou have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Faure, Diagnosed Abnormality of Heart Rhythm Ifthe above condition(s) iar presnt answer question 3-34. 1FNO alyZhwestion 4 3a, Do you have difficulty controlling your condition with medications or other physickan prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) yes_ Cb ‘3b, Do you have an irtegular heat beat that requires medical management? lation, premature ventricular contraction) ves Mo (ea, atrial og ‘3c, Do you have chrome heart failure? yes Clo” 3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular So ysical activity inthe last 2 months? 4, Do you have High Blood Pressure? Ifthe above condition(s) fare present answer question 4a-th. INO 4a, Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? uments) yes Cb “4h, Do you have any a resting blood pressure equal to oF greater than 160/90 malig with or without (Answer NO if'you are not curently taking medications or othe medication? (Answer VES if'you do not know your resting resting blood pressure) yes Co 5, Do you have Metabolic Conditions? This nclales Type I Diabetes, Type 2 Diabetes, Pre-Diabetes exo ebPrucston Sa, Do you often have diffieulty controlling your blood sugar levels with foods, medications, or other physiian-presetibed therapies? YES IF the above consition(s) iar present, answer question 5b. Do you often suffer fom signs and symptoms oflow blood sugar (hypoglycaemia) following exercise andor during activites of daily living? Signs of hypoglycaemia may include shakiness, nervousness, unusual iritability abnormal sweating, dizziness or lght headedness, mental confusion, difficulty speaking, weakness, ot sleepiness. YES) Se. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and or ‘complications affecting your eves. kidneys, OR the sensation in your toes and feet? yes Co Sd. Do you have other metabolic conditions (such as current prew ‘onic kidney pancy-tlated diabet disease, or liver problems)? yes Co Se. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise inthefre? yes Co 6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alcheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Intellectual Disability, Down Syndrome. Ifthe above condition(s) is/are present, answer question 62-6b. INO eGyZhjvestion 7 6a, Do you have dificulty contolling your condition with medications or other physcian-prescribed therapies? (Answer NO if you are nt cureily taking medications of other treatments) vs Do O ‘Gb. Do you ALSO have back problems affecting nerves or mustles? ves Clo C1 7. Do you have Respiratory Disease? This include Chronic Obstructive Pulmonary Diseas, Asthna, Pulmonary High Blood Pressure Ihe above condone pest anser question 76-18 1FNO Lesion ‘a, Do you have difficulty contlling your condition with mesications or other physician-prescrbed therapies? o Oo {Answer NO if you are not currently taking medications of other teatments) 7b. Has your doctor eve id your Hood oxen eel Iowa estor ding exercise andor that you ee supplemental oxygen therapy? vw OO Tes asthmatic, do you eure have symplons of best ihe, wheezing, lowed breathing. consistent cough {more than 2 days/week), oF have you used your reeue medication more than twice inthe last week? vs O OO Ti Has your doctor ever said_you have high blood presure he load vessels of you o 8. Do you have Spinal Cord Injury? This unclude Tetraplegia and Paraplegia the above condition (s) isla present, answer question 8a-8e. INO ao tol tion 9 8a, Do you have difficulty controll your condition with medications of other physician-prescribed therapies? (Answer NO ifyou are not currently taking medications of other treatments) ‘8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, ligh-headednes, andr fuiting? ‘Se, Has your physician indicated dhat you exhibit sudden “boutsof high blood pressure (known as Aulomic Dysreflexia) ves > OO 9, Have you ever had a Stroke? This includes Transient Ischemie Attack (TLA) or Cerebrovascular Event aval ‘9m, Do you have difficulty controlling your conltion with medications of other physickanprescribed therapies? IF the above condition(s) sfare present, answer question 9ae. INO reston 10 {Answer NO ifyou are not currently taking medications of other treatments) Do you have any ban walking or mobiliy? 9. Haye you experienced a stroke or impairment in nerves or muscles in the past 6 months? ws > OO 10, Do you have any other medical condition not listed above oF do you have two or more medical condi Ifyou have oer medical conditions, answer questions 10s I0e. INO reL—bst page (Recommendations) 1a, Have vou experienced a blackout, fainted, of lost consciousness as a result ofa head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months? yes_ > 10, Do you havea medical contiton that snot sted (such s epilepsy, neurological conditions, kidney problems)? ws Cb OO 10¢. Do you cute ine with two oF more medical conditions? PLEASE LIST YOUR MEDICAL CONDITION(S), ut ANDANY RELATED MEDICATIONS HERE, Go to Next page for Recommendations about your current medical condition (s) and sign the PARTI 'LARATION. IPANT.201 PAR Q+ Readiness Questionnaire for Everyone The health benefits of regular physical activity are clear, more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active GENERAL HEALTH QUESTIONS Please read the 7 questions below carefully and answer each one honestly: check YES or NO, YES [NO 1) Has your doctor ever said that you have a heart condition Thigh blood pressure? YM 2) Do you feel pain in your chest at during your dily activities of living, OR when you do physical 3) Do you lose balance because of dizziness OR have you lost consciousness inthe Last 12 months? Please answer NO it your dizeiness was astociated with over-breathing (including during Vigorous exercise). NIN 4) Have you ever been diagnosed with another chronic medical condition (other than heart disease ot high blood pressure)? PLEASE CONDITION(S)HERE: 5) Are you currently taki PLEASE LIST CONDITION prescribed medications fora chronic medical condition? SAND MEDICATIONS HERE: _U?-Srtcami 6) Do you curently have (orhave bad within the past 12 montis) a bone joint, or sof 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 Himit your eurrent ability tobe phy ically sctive. PLEASE LIST CONDITION(S) HERE 7) Has your doctor ever sid hat you sould ony do medically supervised physical atv? VY W Ifyou answered NO to all the questions above, you are cleared for physical activi Go to Page 4 to sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3. Start becoming much more physically active-start slowly and build up gradually Follow — International Physical Activity Guidelines. for your age (www.vho int/dieiphysicalactivity/en/), You may take part in a health and fitness appraisal. If you are over the age of 45 years and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise. If you have any further questions, contact a qualified exercise profe: © Delay becoming more active if: W You have a temporary illness such as a cold or fever, it is best to wait until you feel better, VW You are pregnant- talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARmed-X + at www.eparmedx.com before becoming more physically active.W Your health changes- answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a qualified exercise professional before continuing with any physical activity program