Pre-Consulation Form & PARQ KSC

Pre-Consultation Form - 4 Week Kick Start Challenge

Please complete the following Pre-Consultation Form & we will get back to you within 1-2 working days to discuss your 4 week Challenge!! We look forward to seeing you again...
Name*

First NameLast Name
Birth Date*

DayMonthYear
Occupation
Address*

Street Address

Town

CityState / Province

Post Code
E-mail*
example@example.com
Mobile Number*

Area CodePhone Number
Height
Weight
About You - Family, Social Life, General Lifestyle (not your goals)
What days/times are you available for appointments/sessions?
For example are you only available evenings and weekends or do you prefer mornings or afternoons, if so what times approximately?

Your Goals: Please rank in order of importance with 1 being the most important

	Numbers 1-7	Add any addition details here if required
Lose Body Fat
Gain Muscle
Improve Performance
Get Stronger / Fitter
Health Reasons
Injury Rehabilitation
Other (please state)

General Diet

	Please provide details
How many meals a day do you eat? Are they at specific times?
Do you eat similar meals most days?

What is a typical days food & drink for you? (please include snacks)

	Please show typical food consumed and time eaten (i.e 8.30am Two slices buttered brown toast)
Meal 1
Meal 2
Meal 3
Meal 4
Meal 5
Meal 6

Do you have any allergies / intolerances to foods or anything that you cannot eat?
Do you have any specific cultural needs?

Exercise & Activity : Please be as detailed as you can

Are you a member of a gym / sports club? What fitness activities do you enjoy?
What does your current exercise routine look like? If not current then most recent.
Do you use any fitness equipment at home?
Do you currently track any of the following: Diet, Weight, Measurements, Steps (via a fitness tracker), Sleep, Fluid intake, Training?
Do you drink alcohol or smoke? If so how many cigarettes and/or alcoholic drinks per week?
Do you have any medical needs, diagnosis or conditions? Do you take any supplements or medications?
Do you have any current injuries? Do you have any old injuries regardless of whether they still affect you?
Females Only - If you have children, were there any complications during birth? Did you have a C section?
Is there any other relevant information you feel we should know?

	YES	NO
Have you been diagnosed with a heart condition that requires you to only follow doctor recommended exercises?
Do you feel any pain in your chest when you do physical activity?
In the past month have you experienced any chest pain when you were not doing physical activity?
Do you lose 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 worse by a change in your physical activity?
Is your doctor currently prescribing you medication for a blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

Pre-Consultation Form - 4 Week Kick Start Challenge