ALL 3 INTO 1 FORM ACTIVITY START

Name of Client:   First Name*   Last Name*
Email
Area Code   Phone Number
Height:   Number*
Gender:   *
Weight:   *
Date of Birth:   *
BMI (If not known N/A):   *

What is your occupation?   *

How do you travel to and from your place of work?   *

Describe your activity levels within your occupation.   *

Are you engaging in any physical activity at present? (team sport, individual sport, gym, running etc.)     *

If yes, please describe what is involved and how often a week you exercise.   *

What are your exercise preferences?   *

When are you available to engage in your exercise programme? (days of the week, time of the day)   *

In a few words, what are your reasons for participating in an exercise/swimming programme, and what would you like to achieve? *

What are your barriers to exercise? *

If you are between the age of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Common sense is your best guide when answering these questions. Please read carefully and answer each one honestly: Select YES or NO.

Date*

Birth Date*

MonthDayYear

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Do you feel pain in your chest when performing physical activity? *

Have you experienced chest pain when NOT performing physical activity in the last month? *

Do you lose your balance of dizziness or have you lost consciousness recently?*

Do you have any bone or joint problems such as arthritis, which could be aggraveted through physical activity?*

Is your doctor currently prescribing you medications for high blood pressure or a heart condition?*

Have you had an operation in the last 12 months?*

Is there any reason why you should NOT participate in physical activity?*

IF answered YES to the final question please state the reason below:

IF YOU ANSWERED YES:
If you answered yes to one or more questions, are older than age 40 and have been inactive or are concerned about your health, consult a physician before taking a fitness test or substantially increasing your physical activity.

It would help if you asked for medical clearance and information about specific exercise limitations you may have. In most cases, you will still do any activity you want as long as you adhere to some guidelines.

When to delay the start of an exercise program:

If you are not feeling well because of a temporary illness, such as a cold or a fever, wait until you feel better to begin exercising. If you are pregnant, talk with your doctor before you start becoming more active.

DECLARATION:
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

Client Name: First Name Last Name Date: Date

IF YOU ANSWERED NO:
If you answered no to all the PAR-Q questions, you could be reasonably sure that you can exercise safely and have a low risk of having any medical complications from exercise. It is still essential to start slowing and increasing gradually. It may be helpful to have a fitness assessment with a fitness instructor or personal trainer to determine where to begin.

PLEASE NOTE: If your health changes so that subsequently you answer YES to any of the above questions, inform your fitness or health professional immediately. Ask whether you should change your physical activity or exercise plan.

Having answered YES to one of the above, I have sought medical advice, and my GP has agreed that I may exercise.

Client Name: First Name Last Name Date: Date

PLEASE NOTE: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.

The purpose of an exercise/swimming programme is to help you achieve health and fitness goals. Your schedule will be based upon your present activity/exercise levels and the goals you wish to achieve. You will experience some feeling of exertion during each activity session and become hot and uncomfortable at times. Your breathing and heart rate will increase due to these activities, as would be expected from physical exercise of this type. As your fitness improves, you will participate in more vigorous activity levels if this is part of your goal, but these should remain within your capabilities. All activities will be explained and demonstrated to you, but please feel free to ask questions about anything you wish.

Any exercise programme carries with it an element of risk. Your sessions are designed to minimise the dangers whilst providing an effective exercise/activity programme. Please inform your trainer if, for any reason (such as illness or injury which might be aggravated by exercise or eating certain foods), you should not participate in an activity.

During your sessions with your trainer present, you will be closely supervised. During your sessions where your trainer is not present, you will be responsible for your safety. If, at any time, you feel undue pain or excessive discomfort stop the activity and inform your trainer of your symptoms.

You are free to withdraw from any activity at any time you wish!

I have read, understood and completed the PAR-Q. All questions have been answered to the best of my knowledge. I agree to participate in the programme described to me by my trainer. The nature, purpose, risks and benefits have been explained to me, and I understand what is required of me and that I may withdraw at any time.

I accept the Terms & Conditions regarding payment and cancellation.

Client Name: First Name* Last Name*

Date*

Date

Signature*

Client Screening Questionnaire

Physical Activity Screening

Let's define your Goal Setting!

PAR-Q FORM

INFORM CONSENT FOR TAKING PART IN PHYSICAL ACTIVITY