PAR Q Form

PAR Q Form
COACH FJA

Finn Auchterlonie Coach/PT | 07720 252005 | coachfja@gmail.com
Physical Activity Readiness Questionnaire

(PAR Q)
I am collecting this information so that i can determine wether the client should have a complete medical evaluation before participating in vigarous/strenuous exercise or embark on a nutrition plan. It will be stored on a safe database and kept confidential, if the client should leave the information will be destroyed after 6 months.

General
What are the main reasons you're interested in starting a fitness or nutrition programme?
(general conditioning, to level up your performance in your sport, weight/fat loss, stress management etc)
What would you say are the main barriers preventing you from exercise or eating well?
(Lack of facilities, no motivation, no time, injured, lack of knowledge etc)

Diet & Nutrition
On a scale of 1 to 10 how would you assess the quality of your eating habits?
1 being poor 10 being excellent
Would you like any advice or help in changing the quality of your eating habits?
If you answered the above question (yes) Do you have any allergies or strong dislikes to certain food or drink?
If you answered the question above (NO) please ignore this question

Medical History
Do you drink alcohol?
Do you smoke?
Have you had major illness in the last 5 years?
if yes please give details
Are you receiving treatment for any diagnosed medical conditions?
If yes please give details
Are you taking any prescription medicine?
If yes please give details

Finishing up
Are you currently receiving treatment for any structural problem?
Please indicate any other health problems you suffer from which your have not already mentioned?

I can confirm that i have answered all questions honestly and the information given is correct.
Date

MonthDayYear
Date
Signature
Print Name

First NameLast Name
NOTE: This Par Q becomes invalid should any of your conditions change
Should be Empty:

COACH FJA