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CHESS

Uploaded by

7k4d4rwfh5
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

Name (SN, FN, MI): NISPEROS, John Gabriel C. Student Number: 2021613691
Degree Program BSESS Gender/Age: MALE/21
Course & Section Schedule:

If you’re aged 15-69, the PAR-Q will tell you if you should check with your doctor before significantly
changing your physical activity patterns. Please read each question carefully and answer honestly by
checking YES/NO.

YES NO

Have you ever been diagnosed with any of the following conditions:

1. Heart Disease/problem (sakit sa puso)


2. Asthma (Hika)
3. Kidney/Renal Disease
4. Musculoskeletal Disease
5. Neurological/Brain disease
6. Mental Health concerns/problems /
7. Other long-term medical conditions

If you answered yes to any of the above, please provide details of your medical
condition. ____________________________________________________

______________________________________________________________

______________________________________________________________

Are you taking any medications daily or on a regular basis?

If Yes, please give details: _________________________________________


/
______________________________________________________________

______________________________________________________________

Do you experience chest pain associated with physical exertion?

If Yes, please give details: _________________________________________


/
______________________________________________________________

______________________________________________________________

Do you experience chest pain even while at rest or not doing heavy physical
activity?

If Yes, please give details: _________________________________________ /


______________________________________________________________

______________________________________________________________

Do you have any history of loss of consciousness? /

FEU IE-WRP PAR-Q FORM | Effective January 15, 2024


If Yes, please give details: _________________________________________

______________________________________________________________

______________________________________________________________

Do you have a bone or joint problem (e.g., back, knee, or hip) that could be
/
made worse by a change in your physical activity?

Is your doctor currently prescribing medication for your blood pressure or heart
/
condition?

Do you have other medical/physical conditions that may affect your participation
in FEUAL activities?

If Yes, please give details: __________________________________________ /


______________________________________________________________

______________________________________________________________

If you answered YES to one or more questions, you should consult with your doctor to confirm
that it’s safe for you to become physically active at the current time.

If you answered NO to ALL of the questions, it is reasonably safe for you to participate in physical
activity, gradually building up from your current ability level.

I have read, understood, and accurately completed this questionnaire. I confirm that I am voluntarily
engaging in an acceptable level of exercise, and my participation involves a risk of injury.

SIGNATURE PRINT NAME JOHN GABRIEL C. NISPEROS DATE April 13, 2024

NOTE:

If a student answered YES to any of the questions, the Athletics may refer them to the UHS for further
diagnosis, management, or clearance. Any Medical Certificate submitted is subject to
verification/validation by the UHS.

Thank you.

FEU IE-WRP PAR-Q FORM | Effective January 15, 2024

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