Form

  • Health and Lifestyle Questionnaire

  • Date of Birth*
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  • Physical Activity Readiness Questionnaire

    Being physically active is very safe for most people. Some people, however, should check with their doctors before they increase their current level of activity. The PAR-Q has been designed to identify the small number of adults for whom physical activity may be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.
  • Tick any that apply to you:*

  • If you answered yes:

    If you answered yes to one or more questions, are older than age 40 and have been inactive or are concerned about your health, consult a physician before taking a fitness test or substantially increasing your physical activity. You should ask for a medical clearance along with information about specific exercise limitations you may have.In most cases, you will still be able to do any type of activity you want as long as you adhere to some guidelines.

  • If you answered no:

    If you answered no to all the PAR-Q questions, you can be reasonably sure that you can exercise safely and have a low risk of having any medical complications from exercise.It is still important to start slowing and increase gradually. It may also be helpful to have a fitness assessment with a personal trainer or coach in order to determine where to begin.

  • When to delay the start of an exercise program:

    · If you are not feeling well because of a temporary illness, such as a cold or a fever, wait until you feel better to begin exercising. · If you are or may be pregnant, talk with your doctor before you start becoming more active. Keep in mind, that if your health changes, so that you then answer "YES" to any of the above questions, tell your fitness or health professional, and ask whether you should change your physical activity plan. Source: Selecting and Effectively Using a Health/Fitness Facility. ACSM Fit Society Page. The American College of Sports Medicine Spring

  • Eating Behaviour

  • Do you feel guilty after eating?*
  • Do you feel that food controls your life?*
  • During the past 6 months, have you had episodes when both of the following applied: (a) you have eaten an unusually large amount of food within a two hour period, and (b) you have felt unable to control how much you were eating within these periods?*
  • During the past six months, have you ever done any of the following: Self-induced vomiting in an attempt to control your weight?*
  • During the past six months, have you ever done any of the following: Taken laxatives in an attempt to control your weight?*
  • During the past six months, have you ever done any of the following: Restricted your eating in an attempt to control your weight? (restricted = eating less than 500 calories a day)*

  • Adapted by K. Heidi Fishman, EdD and Marcia Herrin, EdD, Dartmouth College Eating Disorders Treatment Team with permission from The National Eating Disorders Screening Program Screening Questionnaire, Harvard Eating Disorders Center, 1996.

  • General Health

  • Are you currently on any medication?*
  • Are you currently on any birth control?*
  • Are you currently on any HRT?*
  • Rows
  • Do you regularly feel bloated, have gas, or irregular toilet function after eating certain foods?*

  • General Wellbeing

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  • Should be Empty: