PAR-Q (Physical Activity Readiness)

Please fill out the following form.

First name

Last name

Address

Phone

Email

Date of birth

Month

Day

Year

Occupation

Emergency Contact

Full Name, Relationship, phone number

Physician

Full Name, location, phone number

Medical History

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?

No

Yes

Do you frequently have pains in your chest when you perform physical activity?

No

Yes

Have you had chest pain when you were not doing physical activity?

No

Yes

Do you lose your balance due to dizziness, or do you ever lose consciousness?

No

Yes

Do you have a bone, joint, or other health problems that cause you pain or limitations that must be addressed when developing an exercise program?

No

Yes

If yes, please explain (please include previous injuries)

Have you had a recent surgery?

No

Yes

Do you take any medications, either prescription or non-prescription, regularly?

No

Yes

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

Are you pregnant now, or have you given birth within the last 6 months?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Lifestyle Questions

Do you or have you ever smoked?

No

Yes

Do you drink alcohol?

No

Yes

If yes to alcohol, how many and how often do you consume?

How many hours of sleep do you get on average?

How would you describe your job activity level?

Sedentary

Active

Physically Demanding

How often do you travel?

On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)?

List your 3 biggest sources of stress:

Nutrition Questions

On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?

How many times a day do you usually eat (including snacks)?

Do you skip meals?

No

Yes

Do you eat breakfast?

No

Yes

Do you eat late at night?

Sometimes

Often

Never

What activities do you engage in while eating? (TV, reading, etc.)

How many glasses of water do you consume daily?

Do you feel drops in your energy levels throughout the day? If yes, describe

Do you know how many calories you eat per day? If yes, how many?

Are you currently or have you ever taken a multivitamin or any other food supplements? If yes, which ones?

How many times per week do you eat out?

Do you eat past the point of fullness?

No

Yes

Do you eat foods high in fat and sugar? (cookies, processed snacks, chips, crackers, etc)

No

Yes

How would you like to improve your Nutrition?

Fitness Questions

When were you in the best shape of your life?

When did you first start thinking about getting in shape?

What if anything stopped you in the past?

On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?

Are you presently physically active?

No

Yes

If yes, what physical activities are you participating in?

How often do you take part in physical exercise?

5-7x/week

3-4x/week

1-2x/week

If your participation is lower than you would like it to be, what are the reasons?

Lack of Interest

Illness

Injury

Lack of Time

Have you played sports or participated in physical activities in the past? If yes, which ones, when, and for how long?

What is your goal?

Why do you need to achieve this goal?

How committed are you to achieving your goal?

Very

Semi

Not Very

What obstacles may get in the way of achieving your goal?

I declare that the info I’ve provided is accurate and complete by checking this statement and signing below. *If under the age of 18, a parent/legal gaurdian signature is required in addition to the client signature.

Client Signature

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Parent/Legal Gaurdian Signature *Only if under 18 years of age

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Date

Month

Day

Year