PRO ONLINE - QUESTIONNAIRE 1
Please complete as accurately as possible
Your Name
*
First Name
Last Name
Username
*
Password
*
Created at registration
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender
Male
Female
What is your height in centimetres?
*
Please Select
100cm
101cm
102cm
103cm
104cm
105cm
106cm
107cm
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171cm172cm
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Enter your weight in KG
*
What is your goal?
*
Please Select
Lose weight & shape up
Strength & definition
Energy & health
Sports & performance
Physiotherapy
Do you have any injuries or medical conditions?
*
No
Yes
Please specify your injuries or medical conditions:
Are you currently feeling stressed or tired or have trouble sleeping?
*
No
Yes
Please explain:
Do you have any food allergies or special nutritional requirements?
*
No
Yes
Please specify your allergies or nutritional requirements:
Have you exercised before?
*
No
Yes
Please select the exercise type(s):
Weight training
Running
Swimming
Cycling
Racket sports
Other
What is your current daily activity level?
*
Please Select
Not very active
Fairly active
Very active
Highly active
Would you like a Gym or No Gym programme?
*
Gym
No Gym
Please list any equipment you have here:
How many days a week can you commit to excercise?
*
Please Select
1-2
2-3
3-4
4-5
5-7
How much time per day ?
*
Please Select
20-30 mins
30-40 mins
40-60 mins
Are you pregnant or have you had a baby in the last 12 months?
*
No
Yes, I am pregnant
Yes, I had a baby in the last 6 months
Yes, I had a baby in more than 6 months ago
Pre-Activity Readiness Questionnaire (PAR-Q)
Has your doctor ever said that you have arthritis, that has been aggravated by exercise or might be made worse by exercise?
*
No
Yes
Do have high blood pressure?
*
No
Yes
Do you have low blood pressure?
*
No
Yes
Do you have Diabetes Mellitus or any other metabolic disease?
*
No
Yes
Has your doctor ever said you have raised cholesterol
*
No
Yes
Has your doctor ever said that you have a heart condition?
*
No
Yes
Have you ever felt pain in your chest when you do physical exercise?
*
No
Yes
Is your doctor currently prescribing you drugs or medication?
*
No
Yes
Are you currently taking any drugs or medication not prescribed by your doctor?
*
No
Yes
Have you ever suffered from unusual shortness of breath at rest or mild exertion?
*
No
Yes
Do you often feel faint, have spells of severe dizziness or have lost consciousness?
*
No
Yes
Is there any history of heart disease in your family?
*
No
Yes
Are you now, or is there a possibility that you might be pregnant?
*
No
Yes
Do you know of any other reason why you should not take part in physical activity?
*
No
Yes
If you answered YES to one or more PAR-Q questions:
If you have not recently done so, consult with your doctor by telephone or in person before increasing your physical activity and/or taking fitness appraisal. Tell your doctor what questions you answered ‘yes’ to on PAR-Q or present your PAR-Q copy. After medical evaluation, seek advise from your doctor as to your suitability for: 1. Unrestricted physical activity starting off easily and progressing gradually. 2. Restricted or supervised activity to meet your specific needs, at least on an initial basis.
If you answered NO to all PAR-Q questions:
If you accurately answered the PAR-Q, you have reasonable assurance of you present suitability for: 1. A graduated exercise programme, 2. A fitness appraisal.
Assumption of Risk
I hereby state that I have read and understood and answered honestly the questions above. I also state that I wish to participate in activities that may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves the risk of injury. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.
SUBMIT
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