This is your comprehensive client information sheet, in which we will ask you to provide
some relevant personal information. The answers to these questions are essential in order
to allow us to design an optimized individual fitness program for you. Please answer all
questions in the most accurate manner possible while being as concise as possible.

 

Disclaimer:   Please recognize the fact that it is your responsibility to work directly with your physician
before, during, and after seeking fitness consultation. As such, any information provided
is not to be followed without the prior approval of your physician. If you choose to use this
information without the prior consent of your physician, you are agreeing to accept full
responsibility for your decision.

Name *
Name
Phone
Phone
LIFESTYLE INFORMATION
Click which type of progress is more important to you:
Dietary Preferences
Health Goals
Health Goals
Improved health
Improved endurance
Increased strength
Sport-specific
Increased muscle mass
Fat loss
Increased power
Weight gain
Physical Activity Readiness Questionnaire
If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO.
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
2. Do you feel pain in your chest when you do physical activity?
3. In the past month, have you had chest pain when you were not doing 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 (for example, back, knee or hip) that could be made worse by a change in your physical activity?
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
7. Do you know of any other reason why you should not do physical activity?
If you answered YES to one or more questions, Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and to which questions you answered YES.
If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can: Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go. And, Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.
By selecting agree