您最近去过医院就医吗？Have you been hospitalized recently?
如果您有14－19任何情况，请在运动前咨询您的教练If you wrote a Y on any of the questions 12-17, please talk to your instructor before starting.
您还有其它情况可能限制您的运动吗？Are there any other conditions which may be reason to modify your exercise program？
每次运动时间？Exercise duration?
是否曾有医生因为心脏的问题而建议您只能在医疗监督的情形下从事体能活动？Has a doctor ever said you have a heart condition for which you should only undertake physical activity under medical supervision?
您是否在服用处方药？Are you on prescription medication?
何种药物 Type: ____________
治疗作用 Reason for taking: ____________
服用状况 Condition: ____________
建议事项 Recommendations: ____________
药剂量 Dosage: ____________
每周平均运动次数？Frequency per week?
不运动的原因？Reason for not exercising?
希望的运动类型与时间Preference of work-out time?
剧烈程度 Intensity
强烈 Hard
一般 Medium
轻微 Light
声明 Statement:我承认这个运动指导是不能够对我的身体健康给予医学建议，这些信息只是对我的运动具有指导作用。我已经尽全力回答了以上问题并且完全了解这些建议。I recognize that the instructor is not able to provide me with medical advice with regard to my medical fitness and that this information is used as a guideline to the limitations of my ability to exercise. I have answered the questions to the best of my ability and understand the advice above.
下背腰部疼痛Lower back syndrome
对大部分的人而言，从事体能活动是不应该造成任何问题或是危险的。因此，PAR-Q是被设计用来指出其中一小部分可能不适合从事体能活动并且需要在活动进行前寻求医疗咨询以找出合适之活动类型的成年人。常识，是你用来回答这些问题的最佳答案。因此请花几分钟时间仔细阅读回答下列问题。请用Y表示“是”或者用N表示“否”。以下信息所包含的内容是保密的并且任何信息在没有您的书面许可是不会被外泄的。
以下哪些部位疼痛？Which part hurts?
颈部 Neck
膝部 Knees
踝关节 Ankles
肩部 Shoulders
任何肌肉疼痛 Any muscular pain
您在减肥或者绝食吗？Are you dieting or fasting?
您6周内是否分娩过？Have you given birth in the last six weeks?
心悸或胸痛 Palpitations or pain in chest
请更进一步的说明 Further Explanation：
紧急联络人及电话 Emergency contact name and number
紧急联络人Emergency contact name ____________
电话Tel number ____________
您是否有任何因为参与体能活动而导致恶化的骨骼或是关节方面的问题？Do you have a bone or joint problem that could be aggravated by the proposed physical activity?
是否曾有医生因为血压或是心脏方面的问题而对你提出任何的建议？Has a doctor ever recommended any medication for your blood pressure or a heart conditon?
以下是美国运动医学院的建议It is recommended by the American College of Sports Medicine：所有年满35岁的男性或者年满45岁的女性应该拥有一个体检报告，其中应包括运动心电图，胆固醇和脂类含量。that all males over 35 and females over 45 should have a medical assessment, including an exercise E.C.G. and cholesterol lipid count.
血糖不规则或糖尿病 Irregular blood sugar or diabetes
For most people, physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate, or those who should have medical advice concerning the type of activity most suitable for them.Common sense is your best guide in answering these few questions. Please take a few minutes to answer the following questions. Write a Y to indicate YES and an N to indicate NO.The information contained will be treated as confidential and will not be released or revealed without your written consent.
您是否年满35岁（男性）或45岁（女性）且超过3个月未做常规运动？Are you male over 35 or female over 45 who has not done regular exercise for over 3 months?
您运动的目的？Purpose of exercise?
建议事项 Suggestions:1，运动时必须穿着运动服和运动鞋。Please wear proper clothing when exercising.2，运动前应注意自己的身体状况并告知教练。Consult your physician before starting an exercise program.3，养成规律性的运动习惯是促进健康的要点（运动频率，时间，强度）。Exercise frequency, time and intensity are important factors for your progress.4，参加运动者必须却是配合运动与饮食的双方搭配才能效果显著。A healthy diet must accompany your program for optimum results.5，如果未来你有任何疾病或者受伤请重新填写这份表格。If you suffer any illness, injury or condition in the future, please complete this form again.
关节骨骼肌肉运动伤害 Joint, muscle or skeletal injury
我完全了解自己的情况，确认提交Condition cleared.
如果您有1－13任何病史，请咨询医生并且得到他的允许后再进行运动。If you wrote a Y in any of the questions 1-11, please take this form to your doctor and ask for a clearance to exercise before starting any exercise program.
血压大于等于140／90 Blood Pressure=140/90
哮喘或其它肺部疾病 Asthma or other lung diseases
目前是否有规律性，持续性运动习惯？Do you have a regular exercise hobby at present?
高胆固醇 Raised cholesterol/triglycerides
您是否是疤痕性体质，伤口修复力差？Do you presently have any significant scars or wounds you are recovering from?
家族中是否有不满60岁且患有心脏病，中风，高胆固醇，高血压，糖尿病或曾经猝死的人？Has anyone in your family under 60 suffered heart disease, stroke, raised cholesterol or sudden death?
从事何种运动？What type of exercise?
您曾经有过或者现在有: Have you ever had or do you have:
请更进一步的说明: Further Explanation：
您是否从过去的经验，任何医生的建议或是其它体能上的因素而得知自己必须在医疗监察的情形下方可从事运动项目？Are you aware through your own experience or a doctors advice of any other physical reason against your exercising without medical supervision?