F45 Greatwood PAR-Q Form

Full Name

First NameLast Name

Height

Gender

Age

Weight

Please read the following questions carefully and check (X) next to the appropriate answers. Answer all questions honestly and to the best of your ability.

YES/ NO

Rows	Yes	No
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or 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 were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

1. What are your top 2 goals?

2. How would you rate your current nutrition?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

3. How would you rate your current fitness level?

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

4. How can we best help you meet your goals?

5. What is your current occupation?

6. Does your occupation require extended periods of sitting?

7. Does your occupation require extended periods of repetitive movements? (If yes, please explain)

8. Does your occupation require you to wear shoes with a heel?

9. Does your occupation cause you anxiety (Mental Stress)?

10. Do you participate in any recreational activities (golf, tennis, skiing, etc)? (if yes, please explain.)

11. Do have any hobbies (reading, gardening, working on cars, etc.) (if yes, please explain.)

12. Have you ever had any pain or injuries? (ankle, knee, hip, back, shoulder, etc.) (if yes, please explain.)

13. Have you ever had any surgeries? (if yes, please explain.)

14. Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, Please list below)

15. Are you currently on any medication? (If yes, please list)

Signature of Participant:

Type name of Participant

Date

MonthDayYear