PAR-Q

Physical Activity Readiness Questionnaire (PAR-Q)
Please complete all fields marked with a blue bar on the left. These are required.
The remaining questions are optional but help your coach better understand your health history, goals, and needs so we can provide the safest and most effective training experience possible.
About You
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Date of Birth*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Gender Pronouns
CallTextEmailOther
For "other" please indicate preferred method
Emergency Contact Name*

Emergency Contact First NameEmergency Contact Last Name
Relationship
Phone Number*
Emergency contact phone number.Format: (000) 000-0000.
Your Health
Primary Care Provider (PCP) Name:
PCP Phone Number or Email Address:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1. I answered NO to all questions above, and I have been cleared by my health care provider for exercise.2. I answered NO to all questions above, and I have NOT been cleared by my health care provider for exercise.3. I answered YES to one or more questions above, my healthcare provider is aware of these health conditions, and they have cleared me for exercise4. I answered YES to one or more questions above, and I have NOT been cleared by my healthcare provider for exercise.
If you checked box 1 or 3, please sign the release in the next section below.

If you checked box 2 or 4, I highly recommend getting clearance from your healthcare provider before starting an exercise program. Please ask them to provide a signed clearance form and give it to me, along with this PAR-Q form.
Disclaimer & Release
YesNo
YesNo
YesNo
YesNo
YesNo
Signature*
Date*

MonthDayYear
Date
Setting Boundaries

Throughout our coaching partnership, there may be things that come up that you are or are not comfortable talking about. Topics such as your menstrual cycle (or lack thereof), pelvic floor health, nutrition, sleep, and stress may all have an impact on your training and your results to varying degrees. Please indicate which topics you are comfortable talking about with me by checking the relevant boxes (or checking the first box if you are comfortable talking about all of them). If you are not comfortable talking about a certain issue with me, leave the box(es) blank. You may change your decision at any time. As you go through the rest of this form, feel free to leave any questions you don’t feel comfortable answering blank.
YesNo
Menstrual cyclePelvic floor healthIncontinencePelvic organ prolapseMenopauseNutritionEating habits and behaviorsSleepStressEmotional issues and mental healthBody imageWeightOther:
For "other" please indicate
There may also be instances where it can be helpful for me to manually cue or manually assess you, which requires physical touch. Please indicate which body parts you are comfortable having me manually cue or assess by checking the relevant boxes (or checking the first box if you are comfortable having me manually cue or assess all of them). If you are not comfortable having certain areas (or any part of your body) touched for cueing or assessment, leave the box(es) blank. You may change your decision at any time. In addition to your consent here, I will also obtain your verbal consent before manually cueing or assessing you during a training session.
YesNo
FeetLegsHandsArmsHeadGlutesAbdomenUpper backLower backNeckOther
For "other" please indicate
Medical History
Do you have a previous history of injury, pain, or physical limitations with any body parts? If so, please explain:
Have you ever had surgery? If so, when and for what:
YesNoUnknown
If you answered yes, please explain:
PhysiotherapistsChiropractorsAcupuncturistsOther
If you indicated "other" in the previous question, please specify
Please describe the reason(s) for your visit(s) with these medical professionals.
Your Past Birth Experience
Date(s) of birth:
VaginalAssistedC-section
YesNo
If yes, degree of tearing (if known)
YesNo
Is there anything else you want me to know about your past birth experience(s)?
Your Health Details
Heart conditionAsthmaCancerType 1 diabetesType 2 diabetesAutoimmune conditionThyroid diseaseSeizuresFibromyalgiaArthritisBlood disorderOsteoporosisKnee pain or injuryNeck pain or injuryBack pain or injuryOther
For "other" please indicate
Provide details on any boxes checked above.
Are you taking any medications, either over-the-counter or prescription? If so, list them all below.
Have you ever had surgery or experienced any other major medical event you want me to know about? If so, use the space below to share what happened, and when.
Your Training
Gain strengthGain muscleGain body weightLose body fatImprove aerobic fitnessReduce aches and painsImprove overall health and wellnessManage or improve my mental healthHave fun and enjoy fitnessOther
For "other" please indicate
Out of the goals you checked, which ones feel most important? Please rank your top 3.
During a typical week, what types of activity are you currently engaging in and how often?
How’s your exercise routine working for you right now? What, if anything, do you want to change?
How much time can you devote to your training each week? Please explain briefly.
What types of training have you done in the past five years, if any? Did it help you achieve the results you were looking for?
Your Lifestyle

The purpose of the following questions is to help me, as your coach, get a better understanding of your lifestyle. Sleep, nutrition, hydration, and stress all affect your training and recovery. When I have a better understanding of these factors, I can modify your workouts accordingly to ensure you can recover. It also helps us work together to make sure your program leaves you feeling strong and energized.
STRESS & RECOVERY
How much sleep do you get in a 24-hour period?
Rate your general stress level on a scale of 1–10 (1=little, 10=extreme):
Rate your general energy level on a scale of 1–10 (1=exhausted, 10=fully energized):
YesNo
YesNo
NUTRITION
How much water do you drink in a 24-hour period?
Who does most of the grocery shopping & cooking in your household?
What does your nutrition look like on a “typical” day? Please list meals, snacks,and beverages.
What, if any, changes would you like to make to how you’re eating, and why?
ENVIRONMENT
Who do you live with? (e.g., spouse/partner, parents, roommates, pets, children) (optional)
What, if any, major obstacles are you encountering at home or with loved ones when itcomes to your efforts to train, eat, and recover?
INTERESTS
How do you spend your time / what do you do for work?
What are your favorite hobbies (if you have any)?
What is your favorite thing about yourself (physical, mental, personality, etc.)?
What do you believe are your biggest strengths?
What fills you up and brings you joy?
Your Coaching
What drove you to seek out coaching?
What do you hope to get out of your coaching experience?
What do you expect from me as your coach?
Is there anything else you would like to share that I haven't asked you yet?
Should be Empty:

Physical Activity Readiness Questionnaire (PAR-Q)