214Fit New Client Questionnaire

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Readiness to Change* This field is required.Answer questions to the best of your ability.
Yes
No
Are you looking to change a specific behavior?
Row 0, Column 0
Row 0, Column 1
Are you willing to make this behavioral change a top priority?
Row 1, Column 0
Row 1, Column 1
Have you tried to change this behavior before?
Row 2, Column 0
Row 2, Column 1
Do you believe there are inherent risks/dangers associated with not making this behavioral change?
Row 3, Column 0
Row 3, Column 1
Are you committed to making this change, even though it may prove challenging?
Row 4, Column 0
Row 4, Column 1
Do you have support for making this change from friends, family, and loved ones?
Row 5, Column 0
Row 5, Column 1
Besides health reasons, do you have other reasons for wanting to change this behavior?
Row 6, Column 0
Row 6, Column 1
Are you prepared to be patient with yourself if you encounter obstacles, barriers,and/or setbacks?
Row 7, Column 0
Row 7, Column 1
Are you looking to change a specific behavior?
Are you willing to make this behavioral change a top priority?
Have you tried to change this behavior before?
Do you believe there are inherent risks/dangers associated with not making this behavioral change?
Are you committed to making this change, even though it may prove challenging?
Do you have support for making this change from friends, family, and loved ones?
Besides health reasons, do you have other reasons for wanting to change this behavior?
Are you prepared to be patient with yourself if you encounter obstacles, barriers,and/or setbacks?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
1 of 8
5
This is a questionnaire for people ages 15-69.

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check in with their doctor before they start becoming more physically active.

If you are planning to become much more active than you are now, start by answering several questions that are coming up. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check in with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.
6
PAR-Q and YOU* This field is required.Common sense is your best guide when you answer the upcoming questions. Please read the questions fully and answer each one honestly..
Yes
No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Row 0, Column 0
Row 0, Column 1
Do you feel pain in your chest when you do physical activity?
Row 1, Column 0
Row 1, Column 1
In the past month, have you had chest pain when you are not doing physical activity?
Row 2, Column 0
Row 2, Column 1
Do you lose your balance because of dizziness or do you ever lose consciousness?
Row 3, Column 0
Row 3, Column 1
Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worst by a change in your physical activity?
Row 4, Column 0
Row 4, Column 1
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Row 5, Column 0
Row 5, Column 1
Do you know of any other reason you should not do physical activity?
Row 6, Column 0
Row 6, Column 1
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you are not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worst by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason you should not do physical activity?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
1 of 7
7
If you answered YES to one or more questions:

Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the questions you answered YES to on the PAR-Q and You.

You may be able to do activity you want - as long as you startslowly and build gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your dcotor about the kinds of activities you wish to participate in and follow his/her advise.

Find out which community programs are safe and helpful for you.

If you answered NO to ALL questions:

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:

start becoming much more physically active - begin slowly and build up gradually. This is the safest method.

take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.

if you are not feeling well because of temporary illness such as a cold or a fever, wait until you feel better; or

if you are or may be pregnant - talk to your doctor before you start becoming more active.

*If you health changes so that then you answer YES to any of the questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.
8
History Questionnaire Download* This field is required. Please download and fill out. Send completed form to 214fit@gmail.com.
9
* This field is required.Please download and fill out. Send completed form to 214fit@gmail.com.
10
Terms and Conditions* This field is required.
Should be Empty: