PAR-Q

Please read the questions very carefully and answer each one honestly by putting a check
at the blank provided for.

1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity
recommended by a doctor?
(Sinabihan ka na ba ng Doktor mo na ikaw ay may karamdaman sa puso at ang dapat mo lang gawing
pisikal ay ang rekomendado ng Doktor?)
YES (00) _____ NO (HINDI) _____
2. Is your Doctor currently prescribing drugs for your blood pressure or heart condition?
(Kasalukuyan ka bang umiinom ng gamot na inirineseta ng Doktor mo para sa mataas na presyon ng dugo o
karamdaman sa puso?)
YES (00) _____ NO (HINDI) _____
3. Do you experience pain or discomfort in the chest, neck and jaw area during mild physical activity or at rest?
(Nakakaramdam ka ba ng sakit o karamdaman sa dibdib, leeg o gawing panga habang gumagawa ng
malumay na gawaing pisikal o kaya nagpapahinga?)
YES (00) _____ NO (HINDI) _____
4. Do you experience shortness of breath with mild physical exertion?
(Nakakaramdam ka ba ng kahirapan sa paghinga habang gumagawa ng malumay na gawaing pisikal)
YES (00) _____ NO (HINDI) ____
5. Do you get tired frequently even when not doing physical activity or are you frequently drowsy?
(Madalas ka bang napapagod maski na walang ginagawang pisikal o madalas ka bang nananamlay?)
YES (00) _____ NO (HINDI) _____
6. Have you lost weight rapidly recently with or without feelings of extreme hunger?
(Namayat o nawalan ka ba ng timbang ng sobrang bilis kamakailan, o ng hindi nakakaramdam ng matinding
gutom?)
YES (00) _____ NO (HINDI) _____
7. Do you have bone or joint pain that increases with movement?
(Ikaw ba ay may nararamdaman sa sakit sa buto o kasu-kasuan na lumalala pag gumagalaw? May biglang
pagtindi ng sakit ba kung binabaluktot o hinahawakan ang kasu-kasuan?)
YES (00) _____ NO (HINDI) _____
8. Do you know of any other reason why you should not do physical activity?
(Meron ka bang alam na iba pang dahilan kung bakit hindi ka dapat gumawa ng kahit ano mang gawaing
pisikal?)
YES (00) _____ NO (HINDI) _____

If you answered YES to any question, please submit/attach medical certificate.

Thank You. (Pag may sinagutan kayo ng OO, maari lang magpakita sa nagkakaloob ng pagkalinga sa
kalusugan. (Salamat).

______________________________ FW01 ___________________

Student Signature over Printed Name Date Sign
(Lagda ng Estudyante sa ibabaw ng Pangalan) (Petsa nang Nilagdaan)

________________________________
Parent/Guardian Signature over Printed Name
Parent/Guardian in Case of Minor
(Lagda ng Magulang/Tagapangasiwa
kung Menor de Edad)