PAR-Q FORM

Please mark YES or No to the following:

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Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? Yes/No
Do you frequently have pains in your chest when you perform physical activity? Yes/No
Have you had chest pain when you were not doing physical activity in the past month? Yes/No

Do you lose your balance due to dizziness or do you ever lose consciousness? Yes/No
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? yes/no

If you have marked YES to any of the above, please elaborate below:

Are you pregnant now or have given birth within the last 6 months? Yes No
have you had a recent surgery? Yes No
Do you take any medications, either prescription or non-prescription, on a regular basis? Yes No
What is the medication for?
How does this medication affect your ability to exercise or achieve your fitness goals?

Lifestyle

Do you smoke? Yes No If yes, how many?____________
Do you drink alcohol? Yes No If yes, how many glasses per week? _____________ How many hours do you regularly sleep at night?____________
Describe your job:

Sedentary/desk

Active/Physically Demanding Does your job require travel? Yes No

MINDSET

List your 3 biggest sources of stress?
1.
2.
3.
HAVE YOU EVER BEEN DIAGNOSED WITH A MENTAL HEALTH CONDITION? YES/NO

IF YES, PLEASE SPECIFY____________________
on a scale of 1-10, how would you rate your overall state of WELLBEING in your life?______________ (1=very poor - 10=excellent)

Nutrition
On a scale of 1-10, how would you rate your Nutrition? _____________ (1=very poor - 10=excellent)

How many times a day do you usually eat (including snacks)? __________________
Do you eat late at night?
What activities do you engage in while eating? (TV, reading, WORKING etc.) ______________________________ Do you skip meals? Yes No

Do you eat breakfast? Yes No
How many glasses/LITRES of water do you consume daily?_________ GLASSES/LITRES
Do you feel drops in your energy levels throughout the day? Yes No
IF YES, AT WHAT TIME DO YOU GENERALLY FEEL THIS? ______________________________
Do you know how many calories you eat per day? Yes No If yes, how many? _______________ Are you currently or have you ever taken a multivitamin or any other food supplements? Yes No IF yes, please SPECIFY:

At work do you usually: Eat Out/Bring Food How many times per week do you eat out?
Do you do your own grocery shopping? Yes No Do you do your own cooking? Yes No

Besides hunger, what other reason(s) do you eat? PLEASE SELECT ALL THAT APPLY

Boredom Social ENJOYMENT Stressed Tired Depressed Happy Nervous

Do you eat past the point of fullness? Often Sometimes Never Do you eat foods high in fat and sugar? Often Sometimes Never List 3

 

Areas of your Nutrition you would like to improve:
1.

2. 3.

Fitness

FITNESS HISTORY

When were you in the best shape of your life?
When did you first start thinking about getting in shape?
What if anything stopped you in the past? e.g. illness, injury, lack of time, stress
On a scale of 1-10, how would you rate your present fitness level (1=Worst - 10=Best)? On a scale of 1-10, how would you like your fitness level to be (1=Worst - 10=Best)?

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FITNESS BEHAVIOURS

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where or how do you prefer to exercise (e.g. gym, home, outside, in groups, alone)?
Realistically, how often a week would you like to exercise? _______times per week realistically, what times of the day would you like to exercise? Morning Afternoon Evening Realistically, how much time would you like to spend during each exercise session? ______ minutes What are the best days during the week for you to commit to your exercise program? Mon Tue Wed

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Goal Setting

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Please list in order of priority, the fitness goals you would like to achieve in the next 4-12 weeks?

1.
2.
3.

how will you feel once you’ve achieved these goals? Be specific.

on a scale of 1-10, How committed are you to achieving your fitness goals? (1= not at all committed - 10= completely committed)

Thu Fri Sat Sun

What are the 3 most important things your Personal Trainer can do to help you achieve your fitness goals?

1.
2.
3.

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Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals:

(i.e. not training consistently, upcoming vacation, busy season at work, not following the programme, allowing other responsibilities to become a priority over exercise etc.)

Outline 3 methods that you plan to use to overcome these obstacles:

How did you hear about us? Please tick all that apply: leaflet
website
social media

word of mouth
poster in cafe/shop other_____________

If you were referred to us, who told you about our services?________________

why did you choose to join our community? please tick all that apply Location
Personal Trainers
Word of Mouth

Programs
Cost
Customer Service other_____________

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How far do you live from our training studio? __________ PHYSICAL ASSESSMENT

HEIGHT
WEIGHT MEASUREMENTS
HIP TO WAIST RATIO PLANK
PRESS UPS
WALL SQUAT FLEXIBILITY
BACK EXTENSIONS BEFORE AND AFTER PICS