First Name:

Last Name:

Blood Pressure:

Systolic

Diastolic

Pulse (beats / minute)

1. Tobacco User

2. Exercise Habits

a)

Non user

a)

Intensive occupational and recreational exertion

b)

Cigar, pipe or chew 

b)

Moderate occupational and recreational exertion

c)

< 10 cigarettes per day

c)

Sedentary work and intense recreational exertion

d)

20 cigarettes per day

d)

Sedentary work and moderate recreational exertion

e)

30 cigarettes per day

e)

Sedentary work and light recreational exertion

f)

> 40 cigarettes per day

f)

Complete lack of occupational or exertion

g)

Recently quit (date :________)

3. Heredity

4. Cholesterol & % Fat in Diet

a)

No known family or heart disease

a)

Cholesterol below 180 mg%. Diet contains no animal or solid fats

b)

1 relative CV disease over 60

b)

Cholesterol 181 - 205 mg%. Diet contains 10% animal or solid fats.

c)

2 relatives with disease over 60

c)

Cholesterol 206 - 230 mg%. Diet contains 20% animal or solid fats.

d)

1 relative with disease under 60

d)

Cholesterol 231 - 255 mg%. Diet contains 30% animal or solid fats.

e)

2 relatives with disease under 60

e)

Cholesterol 256 - 280 mg%. Diet contains 40% animal or solid fats.

f)

3 relatives with disease under 60

f)

Cholesterol 280 - 300 mg%. Diet contains 50% animal or solid fats.

Par-Q Pre-Registration Questionnaire.  Please circle yes or no for each question.

1.            Has your physician ever said you have heart trouble? 

2.            Do you frequently have pains in your heart and chest?

3.            Do you often feel faint or have spells of severe dizziness?

4.            Has a physician ever said your blood pressure is too high?

5.      Has your physician 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?

6.      Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?

Yes      No

Yes      No

Yes      No

Yes      No

Yes      No

Yes      No