MPP PAR-Q Assessment My Prime Performance PAR-Q Assessment This form must be filled out prior to initial services with My Prime Performance. Name(Required) First Last Today's Date(Required) MM slash DD slash YYYY Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Email Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact InformationName(Required) First Last Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship to You(Required)QuestionnaireBefore we begin your wellness journey, please take a moment to answer the questions below. This helps us keep your safety and success at the heart of everything we do. Please answer YES or NO to each of the following:Has a doctor ever told you that you have a heart condition, or that you should only do physical activity recommended by a doctor?(Required) Yes No Do you ever feel chest pain during physical activity?(Required) Yes No Have you had chest pain in the past month, even when not active?(Required) Yes No Do you ever feel lightheaded, dizzy, or lose your balance during everyday activities or when exercising?(Required) Yes No Have you ever lost consciousness (fainted)?(Required) Yes No Do you have any current joint or bone problems (e.g., arthritis, past injuries, limited mobility) that could be made worse by movement?(Required) Yes No Are you currently taking medication for blood pressure, heart conditions, or other chronic health issues?(Required) Yes No Do you have any long-term health conditions (e.g., diabetes, asthma, cancer, MS, etc.) that may affect your ability to exercise safely?(Required) Yes No Has your doctor ever advised against increasing your physical activity?(Required) Yes No Is there any other reason (not listed above) that you feel might affect your ability to participate in a fitness and wellness program?(Required) Yes No Please describe any other reason (not listed above) that you feel might affect your ability to participate in a fitness and wellness program.(Required)If You Answered “YES” to Any Questions:I may request a quick note from your doctor to ensure that it’s safe to start your fitness journey. Don’t worry — I'm here to support you every step of the way!Confirm and ConsentBy entering your name, the date, and clicking the consent button below, you are confirming the information above to be 100% accurate to the best of your knowledge and consenting to begin receiving fitness instructions and/or guidance by My Prime Performance. Name(Required) First Last Date(Required) MM slash DD slash YYYY Consent(Required) I confirm all information above is correct to the best of my knowledge
