Physical Activity Readiness Questionnaire
Do you experience dizziness, loss of balance, or episodes of fainting or loss of consciousness?
*
Yes
No
Have you been diagnosed with a heart condition or cardiovascular disease?
*
Yes
No
Has a physician ever advised you to limit your physical activity or to participate only in medically supervised or prescribed exercise?
*
Yes
No
Do you experience chest pain during physical activity or exercise?
*
Within the past month, have you experienced chest pain or discomfort during physical exertion?
*
Yes
No
Do you have any bone, joint, or musculoskeletal conditions that could be aggravated or worsened by changes in physical activity?
*
Yes
No
If you have a heart condition, are you currently taking medication for blood pressure, heart disease, or related conditions?
*
Yes
No
Is there any other medical, physical, or health-related reason why you should not engage in physical activity or exercise?
*
Yes
No
Have you ever been diagnosed with metabolic, respiratory, or neurological conditions (e.g., diabetes, asthma, epilepsy) that may affect your ability to exercise safely?
*
Yes
No
Are you currently experiencing unexplained shortness of breath at rest or during mild physical activity?
*
Yes
No
Have you undergone surgery, hospitalization, or significant medical treatment within the past 12 months that may impact physical activity or exercise participation?
*
Yes
No
Please list all past or current injuries or medical conditions for which you have received surgery, physical therapy, or rehabilitative treatment.
Please describe your primary fitness goals. Be as specific as possible and include measurable outcomes such as weight, body fat percentage, strength improvements, performance benchmarks, mobility improvements, or conditioning capacity, along with an estimated time-frame.
Personal Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
Date of Birth
-
Month
-
Day
Year
Date
Height
Weight
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
I acknowledge that participation in physical training and exercise carries inherent risks. I confirm that I have disclosed all known medical conditions, injuries, and health limitations that may affect my ability to participate safely. I understand that it is my responsibility to consult with a physician prior to beginning any exercise program if I have concerns regarding my health. I agree to follow all instructions provided by the trainer and assume responsibility for my participation in physical activity.
*
Date
-
Month
-
Day
Year
Date
Please confirm you are human (cyborgs, squirrels, and Terminators are not eligible).
*
Submit
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