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Revised PPAR-Q Aug. 2022
Revised PPAR-Q Aug. 2022
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?
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.)
Please affix
your recent
1”x1”
photo
I hereby confirm that the information given in this form is true and correct to the best of
my knowledge and belief.
In case of emergency:
Home Address: Blk 29 Lot 10, Narra Street, Fiesta Communities Porac II A, Manibaug
Paralaya
Porac, Pampanga
He/She should not participate in activity at this time pending further evaluation.
__________________________________________________________________________
*Please attach medical records or certificates if found with any medical conditions upon
submission of this form.