Organic Adventures coaching - Health & Consent Form
Please provide your details and complete the PARQ to get started with your health journey. This form identifies any potential risks prior to participation to ensure your safety.
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
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Day
Please select a month
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Month
Please select a year
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Year
Gender Identity
Male
Female
Non-binary
Prefer not to say
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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-
Area Code
Phone Number
Email Address
*
example@example.com
Emergency Contact (ICE) - Full name
*
First Name
Last Name
Emergency Contact (ICE) - Phone number
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-
Area Code
Phone Number
Emergency Contact (ICE) - Relationship
Physical Activity Readiness Questionnaire (PAR-Q)
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
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Yes
No
Do you feel pain in your chest when you do physical activity?
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Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
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Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
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Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
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Yes
No
Is your doctor currently prescribing medication?
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Yes
No
Do you have diabetes or prediabetes?
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Yes
No
Do you have asthma or any other respiratory condition that requires medication?
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Yes
No
Do you currently smoke or vape or have quit within the last six months?
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Yes
No
Are you currently pregnant or have given birth in the last twelve months?
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Yes
No
Do you know of any other reason why you should not do physical activity?
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Yes
No
If you answered YES to any of the above, please provide details.
In addition you can use this space to list any other medical conditions not mentioned above.
Do you have any medical conditions, learning difficulties, other diagnosed conditions, specific communication needs or anything else that you'd like to share to so I can support you better?
Do you have any current injuries? Long term injuries? Injuries in the past 5 years? Please use this space to provide details.
Current Physical Activity level
On average, how many hours do you currently exercise over a week?
Please Select
Not at all
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8+
What does this look like? What types of exercise or training do you do?
How long have you been training consistently?
Less than 6 months
6 months - 1 year
1 - 2 years
More than 2 years
On a scale of 1–10, how would you rate your current general health and well-being? 1 being very poor health and well-being, 10 being peak health?
What would you like to improve in your general health & wellbeing?
What is your number one fitness or health goal right now?
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Declaration and consent
*
Can we share your photo or films online to celebrate success or use for marketing materials?
*
Yes
No
Submit
Submit
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