PAR Q FORM
This form will be an essential tool for your trainer to use to build your training plan
Full Name
*
First Name
Last Name
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
BIRTHDAY
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your goal weight?
*
This is not just for weight loss- we also include gains too
How tall are you?
*
feet & inches please
Do you feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
What health goals would you like to achieve in the next 3 months?
What are your main reasons for starting one on one training? Choose reasons below.
*
Stress Management
General Conditioning
Weigh & Fat Loss
Flexibility
Improve Self Esteem
Health Concerns
Appearance
Upcoming Event
How would you describe your overall health and fitness? (Please be specific)
*
Have you ever done any structured Exercise Programs in the past?
*
Yes
No
What would you say are the main barriers preventing you from exercising? Choose barriers below
*
Lack of Facilities
Illness or Injury
Lack of Time
Lack of Support
Lack of Motivation
Lack of Knowledge
Work
Uncomfortable in gyms
On a scale of 1-10, how would you rate the quality of your eating habits?
*
1 being worst and 10 being best
Do you drink alcohol?
*
Yes (habitually)
No (never)
Occasionally
Do you smoke?
*
Yes
No
I used to but I quit
Have you had a major illness or injury in the last 5 years?
*
Are you receiving treatment for any diagnosed medical condition? (reply NA if not)
*
Are you taking any prescription medication? If yes, what for and if no reply NA
*
Please indicate if you ever experience any of the following symptoms. Do you:
*
ever get unusually short of breath?
ever had joint pain?
ever had severe dizzy spells or fainting?
ever had problems voiding or with bowel movement?
currently pregnant or have given birth in the last 6 months?
None of these apply to me
What areas of your body are you most concerned with? check all that apply
*
Back
Chest
Arms
Belly/abdomen
Hips
Buttocks
Legs
By checking this box, I hereby state that I have read, understood and answered honestly the pre-exercise questionnaire (PARQ screening form). Any questions I had were answered to my full satisfaction. I also state that I wish to participate in activities. I confirm that I have answered all questions honestly and that the information I have given is correct. Note: This PARQ becomes invalid should your condition change.
*
Agreed
Signature
*
Today's date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: