Primary Focus & PAR-Q Form

1
Name* This field is required.
2
Date of birth
Date
Month
Day
Year
3
Gender
Male
Female
4
Estimated weightlbs
5
What is your primary health goal?* This field is required.
Strength & flexibility
Conditioning & cardiorespiratory health
Stress management
6
Phone Number
Please enter a valid phone number.
7
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Emergency Contact (Name, Phone #)* This field is required.
9
How do you prefer me to contact you?
Email
Phone
Text
Video Chat
Other
10
In 6 months, what would you like to achieve
11
Have you recently in the past 12 months been diagnosed with any of the following (check all that apply):* This field is required.
Cardiovascular Disease
Diabetes
Cancer
Neurological Disorder
Respiratory Issues
Haemorrhoids/Hernia/Abdominal Surgery
Other
None
12
If diagnosed with any of the above, please explain:
13
Has a doctor ever said you have a heart condition or high blood pressure?* This field is required.
YesNo
14
If Yes, please explain and include relevant information (medication, surgeries, contraindications to physical activities, etc.)
15
Do you feel pain in your chest at rest, during regular daily activities or during physical activity?* This field is required.
YesNo
16
If Yes, please explain and include relevant information (medication, surgeries, contraindications to physical activities, etc.)
17
Do you lose balance because of dizziness or have you ever lost consciousness in the past 12 months?* This field is required.
YesNo
18
If Yes, please explain and include relevant information (medication, surgeries, contraindications to physical activities, etc.)
19
Have you ever been diagnosed with another chronic medical condition?* This field is required.
YesNo
20
If Yes, please explain and include relevant information (medication, surgeries, contraindications to physical activities, etc.)
21
Are you currently taking prescribed medications for a chronic medical condition or supplements for general health?* This field is required.
YesNo
22
If Yes, please explain and include relevant information (medication, surgeries, contraindications to physical activities, etc.)
23
Do you currently have any bone, joint or soft tissue injuries that may become worse with physical activity?* This field is required.
YesNo
24
If Yes, please explain and include relevant information (medication, surgeries, contraindications to physical activities, etc.)
25
Has a doctor ever said you should only participate in medically supervised physical activity?* This field is required.
YesNo
26
If Yes, please explain and include relevant information (medication, surgeries, contraindications to physical activities, etc.)
27
Are you pregnant?* This field is required.
YesNo
28
Do you feel tense?
(0) never/not true at all
(1) occasionally/a bit true
(2) frequently-mostly true
(3) very frequently/very true
29
Do you feel a cold sensation in your hands or feet?
(0) never/not true at all
(1) occasionally/a bit true
(2) frequently-mostly true
(3) very frequently/very true
30
Do you notice yourself yawning?
(0) never/not true at all
(1) occasionally/a bit true
(2) frequently-mostly true
(3) very frequently/very true
31
Do you notice breathing through your mouth at night?
(0) never/not true at all
(1) occasionally/a bit true
(2) frequently-mostly true
(3) very frequently/very true
32
Do you notice dry mouth mouth when waking?
(0) never/not true at all
(1) occasionally/a bit true
(2) frequently-mostly true
(3) very frequently/very true
33
How would you describe your pain tolerance?
Low (highly aware and sensitive to physical sensations of my body)
Medium (not sensitive, but aware of physical sensations of my body)
High (not sensitive and unaware of physical sensations of my body)
34
Are you currently seeing any of the below practitioners? (Check all that apply)
Physical Therapist
Massage Therapist
Chiropractor
Orthopaedist
Acupuncture
Other
None
35
Currently, are you regularly active in sports and /or exercise?
YesNo
36
Please describe your current exercise and fitness routine. How many days/week do you exercise? How many hours/week do you exercise? What is your goal: Cardiovascular Improvement, Muscular Strength and Endurance, and/or Flexibility (include specific body parts/areas of focus)? What exercises do you perform: Exercise name, duration, intensity (low, medium or high), etc. Be as thorough as you are able to be.
Huge
Large
Normal
Small
Ok
Ok
37
Approximately how much time per day do you do non-exercise related physical activity?
<20 mins
20-40 mins
> 40mins
38
Approximately how many hours per day are you seated?
<4 hrs
4-6 hrs
>7 hrs
Should be Empty: