• Client Intake Form

    Please provide as much information as possible
  • Format: (000) 000-0000.

  • (PAR-Q) Physical Activity Readiness Questionnaire

    This form is strictly confidential.
  • Have you ever been diagnosed with a bone or joint problem?
  • Do you have any history of high or low blood pressure?
  • Do you have any history of metabolic diseases, i.e. diabetes?
  • Do you have any history of high cholesterol?
  • Do you have any history of heart conditions that could affect your ability to exercise?
  • Have you ever experienced pain in your chest while exercising?
  • Are you currently taking any medications, drugs, or supplements prescribed or otherwise?
  • Have you ever experienced a shortness of breath at rest or under mild exertion?
  • Do you have history of heart disease in your family?
  • Do you experience spells of dizziness or blackouts?
  • Are you currently pregnant?
  • Do you know of ANY other reason that could prevent you from participating in a physical activity program?

  • If you answered YES to any of the questions above and have not already done so, please consult with your doctor before participating in any exercise programs.

  • Should be Empty: