PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)
Name (SN, FN, MI): BANAC, MABEL JESUS C. Student Number: 2019151471
Degree Program INSTITUTE OF EDUCATION Gender/Age: Male/23
Course & Section Bachelor of Science in Exercise and Schedule:
Sports Science Major in Fitness and
Sports Management
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: _________________________________________
/
______________________________________________________________
______________________________________________________________
FEU IE-WRP PAR-Q FORM | Effective January 15, 2024
Do you have any history of loss of consciousness?
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 BANAC, MABEL JESUS DATE APRIL 14, 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
