Questionnaire
If you are planning to become more physically active than you are now, please start by answering the seven questions 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 the age of 69 and you are not used 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? NO to all questions.
If you have answered NO to all Par-Q questions, you can be reasonably sure that you can:
-start becoming much more physically active
-it is also recommended that you have your blood pressure evaluated. If you reading is over 144/94, talk to your doctor before becoming more physically active.
Yes to any one or more questions or if you are or may be pregnant.
Please talk to your doctor before becoming more physically active.
By clicking below, I confirm that I have understood and completed this questionnaire and all questions I had were answered to my full satisfaction. I also understand that any physical activity carries with it a certain amount of risk and I assume all responsibility for any injury, accident or harm that may come from my participating in this program.
Clicking the "Submit" button will automatically email a representative and will contact you to book your no obligation or fee consultation. If you wish, you may also contact us to book your appointment.
Contact information 905 337-7348 or info@resultsfitnessstudio.com
First name:
Last name:
Date of Birth:
Home Phone:
Business Phone:
Address:
Building:
City:
Province:
Postal Code:
Email:
Physician:
Promotion Code:
PERSONAL INFORMATION AND BACKGROUND
Are you presently exercising?
Type of exercise:
Frequency: Duration:
Duration:Have you ever had a personal trainer?
Frequency: Duration:
Duration:If Yes, what did you like:
Most:Least:
Least:How would you rate your experience with your trainer:
Do you participate in any recreational activities?
If Yes, please list:
Are you happy with your present physical state?
Does your present physical state prevent you from taking part in any activities?
How did you hear about us?
Occupation:
What do you do for stress release?:
Do you smoked?
Do you drink alcohol?How many drinks per week, average?:
How many drinks per week, average?:How many hours do you sleep per night?:
Please indicate which meals and what foods you eat daily?
Breakfast:
Snack:
Lunch:
Snack:
Dinner:
Snack:
Other:
Do you take vitamins and/or minerals?:
If Yes, please indicate:
MEDICAL BACKGROUND
Do any of the following relate to you?
Please explain:Are you accustomed to vigorous exercise?
Are you pregnant?
Are you presently taking any medications?
If yes, please list:
PERSONAL GOALS
Increase Lean Muscle and Strength:
Fat Loss:
Improve Health and Fitness:
Total Body Transformation:
Other:
Do you wish to train for a specific event, occasion or sport?
If yes, please indicate:
Are you interested in in-home personal training?
If yes, please list all equipment that you have in your home:
PAR-Q & YOU
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