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Get NAVPERS 6110/3 2011

PHYSICAL ACTIVITY RISK FACTOR QUESTIONNAIRE PARFQ NAVPERS 6110/3 07-2011 Supporting Directive OPNAVINST 6110. 1 Privacy Statement AUTHORITY 10 U*S*C. 5013 Secretary of the Navy OPNAVINST 6110. 1J Physical Readiness Program* PRIMARY PURPOSE The Physical Activity Risk Factor Questionnaire PARFQ is a self-screening tool required of all Navy members prior to participating in the semi-annual Physical Fitness Assessment PFA. The form assists commands and medical personnel in identifying risk factors or changes in a member s health status since the completion of the annual Physical Health Assessment PHA. ROUTINE USES Disclosures are permitted under 5 U*S*C. 552a b Privacy Act of 1974 as amended* DISCLOSURE Mandatory. Failure to fully disclose the requested information may inhibit the Navy s ability to properly assess your physical activity risk factors and may subject you to administrative actions. NAME DATE OF YOUR LAST PHA DATE OF BIRTH 1. Are you 50 years of age or older YES NO 2. Has anyone in your immediate family had a heart attack died from a heart condition or died suddenly before age 50 as a result of a medical condition the skeletal system cardiovascular system eyes and skin 4. Has your healthcare provider told you that you have a heart problem or other medical condition such as sickle cell trait which limits your activities 5. Has a healthcare provider ever counseled you on or prescribed medication for an increased lipid cholesterol or triglyceride level s 6. Do you feel pain in your chest when you do physical activity 7. In the past month have you had chest pain when you were NOT doing physical activity 8. Have you ever become lightheaded or dizzy passed out or nearly passed out during or after exercise 9. Do you have a bone or joint problem for example back knee or hip that could be made worse by a change in your physical activity 10. Is your healthcare provider currently prescribing medications for example water pills for a blood pressure or heart condition 11. Females Are you now or do you think that you may be pregnant 12. Are you a current smoker or have you quit smoking within the past 3 months 13. Do you know of any reason why you should not do physical activity 14. DATE 15. MEMBER S SIGNATURE To Be Completed By Medical PARFQ Screening completed on Member is cleared to participate in the PRT. Member incurred a waiver If yes attach a copy of the medical waiver PRINT NAME OF MDR Reset Form Verified Date Of Last PHA SIGNATURE OF MDR FOR OFFICIAL USE ONLY PRIVACY SENSITIVE DATE Save Print Form. 1 Privacy Statement AUTHORITY 10 U*S*C. 5013 Secretary of the Navy OPNAVINST 6110. 1J Physical Readiness Program* PRIMARY PURPOSE The Physical Activity Risk Factor Questionnaire PARFQ is a self-screening tool required of all Navy members prior to participating in the semi-annual Physical Fitness Assessment PFA. The form assists commands and medical personnel in identifying risk factors or changes in a member s health status since the completion of the annual Physical Health Assessment PHA. .

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