2. Do you frequently have pains in your chest?—Yes / No

3. Do you often feel faint or have spells of severe dizziness?— Yes / No

4. Has a doctor ever said that your blood pressure was too high or low?— Yes / No

5. Has your doctor ever told you that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise, or might be made worse by exercise? —Yes / No

6. Is there any physical reason not mentioned here why you should not follow an activity program even if you want to?— Yes / No

7. Are you over the age of 65 and not accustomed to vigorous activity? —Yes / No

If you answered YES to one or more questions...
if you have not recently done so, consult with your personal physician by telephone or in person before increasing your physical activity and/or taking a fitness test.

If you answered NO to all questions...
If you answered the PAR Q accurately, you have reasonable assurance of your present suitability for an exercise test.

I hereby state that I am in good health and able to participate in this program. I further state that I have honestly provided all known medical conditions and history asked for and relevant to such a program.

Signed ______________________________________________ Date _______________