EmailMe Form - Physical Activity Readiness Questionnaire (PAR-Q)

Title

First Name *

Last Name *

Age

Email *

Best Contact Phone Number

### - ### - ####

Regular exercise associated with many health benefits, yet any change of activity may increase the risk of injury. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life.

Please read each question carefully and answer every question honestly:

Per your Fitness Center Consultation, do you have a preference of Male or Female Personal Trainer? The orientation will take 45 to 60 minutes, come dressed in athletic attire

Yes

No

What day of the week would you like your consultation?

What time slot would you like your consultation?

6:00 - 11:00 AM

12:00 - 4:00 PM

5:00 - 8:00 PM

Has a physician ever said you have a heart condition and you should only do physicial activity recommended by a physician?

Yes

No

Do you ever lose consciousness or do you lose your balance because of dizziness?

Yes

No

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

Yes

No

Is a physician currently prescribing medications for your blood pressure or heart condition?

Yes

No

Are you currently or recently recovering from an injury?

Yes

No

Do you have insulin dependent diabetes?

Yes

No

Do you know of any other reason you should not exercise or increase your physical activity?

Yes

No

If you answered yes to 3 or more of specific questions listed, medical clearance will be requested. Please talk with your doctor BEFORE you become more physically active. Tell your doctor your intent to exercise and to which questions you answer yes.

If you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually.
If your health changes so you then answer yes to any of the above questions, seek guidance from a physician.

Signature

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Date

MM / DD / YYYY