Health Questionnaire (PAR-Q)

Client Information

Full name

Date of birth

Email address

Phone number

Emergency contact name & number

Section 1: General Health (PAR-Q)

1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

7. Do you have any diagnosed medical conditions that may affect your ability to exercise?

Yes No

8. Are you currently pregnant or recently postpartum (within 6 months)?

Yes No

9. Do you know of any other reason you should not take part in physical activity?

Yes No

If yes to any of the above, please provide more detail

Section 2: Injuries, Pain or Limitations

Do you have any muscle, joint or bone injuries that could impact training?

Have you ever had surgery or physical therapy for any condition?

Do you experience chronic pain or stiffness anywhere in your body?

Are there any exercises or movements you know cause discomfort or aggravate an existing issue?

Is there anything that makes you feel nervous or hesitant about starting or returning to training?

Section 3: Additional Notes / Lifestyle Info

How would you describe your current activity level?

Sedentary Lightly Active Moderately Active Very Active

Do you smoke?

Yes No

How many alcoholic drinks do you consume per week, on average?

Are there any other health or lifestyle concerns you'd like your coach to know about?

Section 4: Consent & Acknowledgment

Signed

Dated

Personal Training Readiness & Health Screening

Client Information

Section 1: General Health (PAR-Q)

Section 2: Injuries, Pain or Limitations

Section 3: Additional Notes / Lifestyle Info

Section 4: Consent & Acknowledgment

Thanks — all done.