HEALTH HISTORY & PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

Please have this completed before your Initial Consultation. Be sure to click SUBMIT at the end.

This Par-Q (Physical Activity Readiness Questionnaire) is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of the PAR-Q is sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people, physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of people for whom physical activity might be inappropriate even though all should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide answering the following questions. Be sure to read each question carefully and check as it applies to you.

Date:
Name
Email
Phone

Let's start with which services interest you most?

Personal Training / Nutrition
Classes / Accountability Coaching

MEDICAL HISTORY

Have you ever had or have been told:*

Heart Attack / Coronary Angioplasty (PCTA) / Heart Surgery / Heart Valve Disease
Heart Transplant / Congenital Heart Disease / Heart Failure / You take heart medication
NONE

Have you ever experienced?

Chest discomfort with exertion? / Dizziness, fainting or blackouts / Unstable breathlessness / NONE

Please explain any items checked:

Blood Pressure:

Normal / >140/ 90 mm Hg / Don't know / Take blood pressure medication

Cholesterols:

Normal / > 200 mg/Dl / Don't know / Take cholesterol medication

Have you ever or currently smoked?

Never / Previous smoker / Currently

You have or Are:

20 pounds overweight / Asthma or other lung disease / Diabetes / Burning or cramping sensation in your lower legs when walking short distances
Drink more than 2 glasses of alcohol per day / Concerns about the safety of exercise / Sleep less than 6 hours per night / Pregnant
Female 55 Years or older / Male 45 years or older / NONE

Family Members have or had:

High Blood Pressure / Diabetes / Cancer / Stroke
Elevated Cholesterol / A close blood relative who had a heart attack or heart surgery before the age of 55 (father, brother or child) or 65 (mother, sister or child). / NONE

PHYSICAL ACTIVITY, MOVEMENT & YOU!

Activity Level:

Beginner / Moderate / Advanced / Physically Inactive – Sedentary

Which type of functional movement do you find yourself doing?

Squat & Reach:

Childcare / Eldercare / Gardening
Horseback Riding / Other

Rotational:

Golf / Tennis / Cheer / Basketball
Baseball /Softball / Hockey/Lacrosse / Other:

Locomotion:

Walk / Hike / Bike / Jog / Run
Swim / Ski/Snowboard / Other:

Seated:

Read / Video Gaming / Sew / Quilt
Other:

Which type of fitness programs you enjoy or have interest?

Yoga / Pilates / Flexibility / Senior Fitness / Gentle / Aerobic: Step / Zumba etc.
Boot Camp / Spin / Body Weight / TRX / Weight Lifting / Strength
Boxing / Kickboxing / Marshall Arts / Endurance Extreme / Other:
List any physical ailments and/or restrictions:

Check any pain symptom areas:

Neck / Shoulders / Back Upper / Back Lower
Hips Front / Hips Back / Knees / Feet
Elbows / Hands / Other: / NONE

Describe your current exercise habits:

Describe your dietary habits:

What are your Goals?

What are you doing now?

Where would you like to be by when?

Anything else you would like to share?