PAR-Q+ Health Questionnaire | Viking Wellness Solu

First name

Last name

Birthday

Month

Day

Year

Email

Sex assigned at birth

Male

Female

Emergency contact name

Relationship

Emergency contact phone number

Height (in inches)

Weight (in pounds)

I understand that if I check yes to any of the below questions, I must detail why.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

No

Do you feel pain in your chest when you do physical activity?

Yes

No

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?

Yes

No

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

Yes

No

Are you currently taking prescribed medications for a chronic medical condition?

Yes

No

Do you currently have (or have had in the past 12 months) a bone, joint, or soft tissue problem that could be made worse by physical activity?

Yes

No

Has your doctor ever recommended that you only do medically supervised physical activity?

Yes

No

Have you had any surgeries or hospitalizations in the past 12 months?

Yes

No

Are you currently pregnant or postpartum (within 12 months)?

Yes

No

Provide a detailed description to any questions above that you answered yes to:

List ALL medications, supplements, and lifestyle additions (peptides, hormones, etc.)

Do you have any allergies?

Yes

No

If so, please list all allergies:

Do you use any tobacco products?

Yes

No

Do you use any alcohol products?

Yes

No

If yes to either tobacco or alcohol, please list amount, frequency, and duration.

Average hours of sleep per night

Occupation/type of work:

I confirm that the information provided above is accurate and complete to the best of my knowledge and understand that withholding relevant medical information may increase my risk of injury. I understand that If answered YES to any of the above questions, Viking Wellness Solutions LLC may require written medical clearance prior to program delivery. Program delivery may be delayed until clearance is received to ensure my utmost safety and health.