Participant Information * First Name Last Name Date of Birth MM DD YYYY Phone (###) ### #### Personal Information Age 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75+ Gender Female Male Prefer Not To Say Preferred Pronouns Emergency Contact Information * First Name Last Name Emergency Contact Phone Number * (###) ### #### Relationship to Participant Health And Fitness Do you have any medical conditions that may affect your ability to participate in physical activity? Yes No If yes, please specify: Are you currently taking any medications that may affect your physical activity or running? Yes No If yes, please specify: Do you have a heart condition? Yes No Do you feel pain in your chest when you do physical activity? Yes No In the past month, have you had chest pain when you were not doing physical activity? * Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? * Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? * Yes No Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? * Yes No If yes, please specify Fitness Background How would you describe your current activity level? * Sedentary Moderately active Active Very active Have you ever been a part of a structured running program before? * Yes No If yes, please describe: Consent and Acknowledgment Consent and Acknowledgment * I understand that I am responsible for monitoring my own condition throughout the running program. If at any point I feel undue pain or stress, I will adjust my activity level and notify a program leader. I affirm that I have read this questionnaire and that my answers are correct to the best of my knowledge. Agree I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that AdaptDaily Wellness may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. * I agree and confirm that all information provided is true and accurate. Date Signed * MM DD YYYY Digital Consent * Please type first and last name and click checkbox for digital consent First Name Last Name Digital Consent * Digital consent Thank you! PARQ+Physical Activity Readiness Questionnaire
