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

What's the best way to contact you?

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:

Permission to Contact PCP if Needed :

1. Has your doctor ever said that you have a heart condition and that you should only perform medically supervised physical activity?

2. Do you feel pain in your chest when you perform physical activity?

3. In the past month, have you had chest pain when you were not performing any physical activity?

4. Do you lose your balance because of dizziness, or do you ever lose consciousness?

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?

6. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

7. Are there any other reasons why you should not engage in physical activity?

Please check the box that is most applicable

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

I, the undersigned, have read, understood to my full satisfaction, and completed this questionnaire.

I understand that if my health changes, I must inform my coach and check with my PCP that I’m still cleared for exercise.

I recognize that it is my responsibility to work directly with my PCP before, during, and after seeking fitness and/or nutrition consultation.

I understand that any information provided is not to be followed without prior approval of my PCP. If I choose to use this information without such approval, I agree to accept full responsibility for my decision.

I acknowledge that my coach may retain a copy of this form for their records. In these instances, they will maintain the confidentiality of the same, complying with applicable law.

Signature

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.

I am comfortable talking about all of the topics listed below.

I am only comfortable talking about these specific topics:

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.

I am comfortable with my coach manually cueing and manually assessing all the body parts listed below.

I am only comfortable with my coach manually cueing and manually assessing these specific body parts:

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:

Are you currently experiencing or have you recently experienced any muscle or joint pain?

If you answered yes, please explain:

Have you met with any of the following healthcare professionals in the past 12 months?

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:

Birth type:

Tearing

If yes, degree of tearing (if known)

Are you currently breastfeeding?

Is there anything else you want me to know about your past birth experience(s)?

Your Health Details

Have you been diagnosed (currently or in the past) with any significant medical conditions and/or injuries that you haven’t mentioned yet? Please check all that apply.

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

In general, what are your goals for training? Check all that apply.

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):

Do you feel depressed or anxious?

Have you ever been diagnosed with depression or anxiety?

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?

Physical Activity Readiness Questionnaire (PAR-Q)