Physical Activity Assessment Questionaire

Physical Activity Assessment Questionaire
Today’s date

MonthDayYear
Date
Name

First NameLast Name
Date of birth
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Phone Number
Please enter a valid phone number.
Emergency Contact Name
Emergency Contact Email and Phone Number
Height
Indicate whether feet / inches or metres
Weight
Indicate if in Kgs or lbs
Waist circumference
For most people, physical activity should not pose any problem or hazard. Par-Q has been designed to identify individuals for which physical activity might be inappropriate or for those who should have medical advice concerning the activity most suitable to them.

If you answer "YES" to any of the first 3 Questions (below), please take a PAR-med X Form to your doctor, have it
filled out and signed and advise them of the activities you are participating in.
1. Have you been diagnosed with a heart condition?

YesNo
2. Do you frequently experience pain in your chest or heart brought on by physical activity?

YesNo
3. Have you been diagnosed with high blood pressure or hypertension?

YesNo
4. Are you currently taking medication? If yes , what medication ?
5. Are you currently suffering from a cold, flu, other ailments ?
Please indicate
6. Have you been diagnosed with Osteoporosis? If yes, where ?
7. Do you have any other bone or joint problems that could be aggravated by the activities in a fitness class? If yes, indicate type of condition.
7. Do you become breathless after walking up a flight of stairs?
8. Do you have diabetes? If yes, are you taking insulin?
9. How many times each week you able to train?

OnceTwoThreeFour5 or more
10. What physical activity do you currently do?
11. Have you previously worked with a coach or online trainer?
12. What is your favourite exercise ? Squat, push-up, planks etc
13. What is your fitness goal?
14. What are your typical meals and snacks in one day? Please include frequency, amount , types? Are these home made? Fast food etc
15. What are your hobbies?
Appointment
Should be Empty: