Personal Information ^*

Full Name ^*

Age ^*

Email

Phone Number ^*

How Did You Hear About Me? ^*

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Personal Information ^*

Height ^*

Weight ^*

Sex ^*

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PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

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1. Has Your Doctor Ever Told You That You Have A Heart Condition Or Have High Blood Pressure? ^*

Yes

No

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2. Do You Feel Pain In Your Chest At Rest, During Your Daily Activities Of Living Or When You Do Physical Activity /Exercise? ^*

Yes

No

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3. Do You Lose Balance Because Of Dizziness Or Have You Lost Consciousness In The Last 12 Months ^*

Yes

No

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4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? ^*

Yes

No

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5. Are You Currently Taking Prescribed Medications For The Chronic Medical Condition? ^*

Yes

No

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6. Do You Currently Have (Or Have Had In The Last 12 Months) A Bone, Joint Or Soft Tissue (Muscle, Tendon, Ligament) Problem That Could Be Made Worse By Becoming More Physically Active? ^*

Yes

No

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7. Has Your Doctor Ever Said You Should Only Do Medically Supervised Physical Activity? ^*

Yes

No

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8. If You Have Diabetes (Type 1 Or 2) Have You Had Trouble Controlling Your Bloody Glucose In The Last 3 Months? ^*

Yes

No

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If you answered NO to all of the questions above you are cleared for activity. If you answered YES to one or more of the above questions, consult your physician before engaging in physical activity. Seek advice from your physician on what activity in suitable for your condition.

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Current Fitness & Exercise Routine

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Do You Smoke? ^*

Yes

No

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If You Smoke, How Many Cigarettes/Day

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Do You Drink Alcohol? ^*

Yes

No

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If You Drink, How Many Drinks/Day?

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How Many Glasses Of Water Do You Drink Per Day? ^*

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How much sleep do you get per night? ^*

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Please indicate your daily stress level ^*

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Are You Currently Doing Any Exercise ? ^*

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Frequency – How Many Times Per Week ^*

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Intensity – Was The Intensity? ^*

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Duration – How Long Did Each Session Last On Average? ^*

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What Are Your Reasons For Engaging A Personal Trainer?

Weight Loss

Improve Fitness

Hypertrophy

Change The Way You Look Or Feel About Your Body

Medical Or Health Reasons

Stress

Rehab

Other

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Many Times Per Week You Will Commit To Your Training Program ^*

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Please List All Past Or Current Musculoskeletal Injuries: ^*

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Please List All Past Surgeries ^*

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Tell Me About Your Current Job And Your Hobbies. ^*

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Thank you for submitting!

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Personal Training Application Form

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

Current Fitness & Exercise Routine

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