PAR-Q
Pre coaching screening questionnaire. PLEASE COMPLETE ALL QUESTIONS.
Name
First Name
Last Name
Age & Occupation
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently physically active? If so, please describe activity and frequency.
Please describe your goal/reason for choosing to invest in coaching.
How committed are you to achieving your goal?
Not ready
1
2
3
4
All in!
5
1 is Not ready, 5 is All in!
Do you track your food?
Yes
No
Previously
Never
How many litres of water do you drink per day?
1
2
3
4
5
1 is , 5 is
Would you prefer
1:1 Coaching
Online Coaching
Do you suffer from any of the following
High or Low Blood Pressure
Autoimmune Disease
Diabetes
Asthma
Do do have any health conditions/ injuries?
Are you currently on any medication? (Incl hormonal contraception/ HRT)
Pre / Post Natal / Pelvic Health
Please give a description of maternal history - e.g. Number of Pregnancies, Gestation, birth experiences, birth related injuries.
Are you currently breastfeeding?
Yes
No
Have you experienced any of the following
Physical Trauma/ Falls
Recent sudden unexplained weight gain or loss
Loss of sensation when you wipe after the bathroom or during sexual activity
Losing control of wind
Blood in stool or urine
Back pain
Pain while going to the toilet or during sex
Mental pain, stress / trauma
Recurrent UTI / yeast infection ( more than 3 per year)
Changes in bowel habits
Emptying the bladder during the night on a regular basis
Heaviness / bulging sensation in the pelvic floor
Changes in menstrual cycle
Thyroid issues
Leaking while coughing, sneezing, jumping, lifting
Leaking while bladder is full/ not making it to the toilet in time
Weight in KG
Height in feet
Where did you hear about Coached by Amber / Strong Mama Online?
Instagram
Recommendation
Facebook
Other
Social Media handle
I accept full and complete responsibility for my own participation in the sessions and for my own physical and emotional well-being at the attainment of the goal we have established. I agree to hold Coached by Amber/StrongMama free and harmless of any and all liability for any death, subsequent injury or health complication that may result from or be aggravated by participating in this program. I acknowledge that attaining my goal will be a result of my responsibility and adherence to the plan prescribed. I understand that I must notify Coached by Amber/ StrongMama at least 24 hours in advance of any changes I wish to make to my training timetable. Failure to do so may result in the session still being charged. I acknowledge that monthly booked sessions operate on a pro-rata basis, with a minimum 3 month subscription and one month notice prior to terminating. Block booked sessions will be carried forward as refunds can not be offered. Sessions must be used within 90 days of purchase.
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