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CLIENT AGREEMENT & PHYSICAL ACTIVITY AND READINESS QUESTIONNAIRE (PAR-Q)
Your Details
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Indicates required field
Full Name
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Age
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Date of Birth (MM/DD/YY)
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Email
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Readiness for Activity
HAS YOUR DOCTOR EVER SAID THAT YOU HAVE A HEART CONDITION AND THAT YOU SHOULD ONLY PERFORM PHYSICAL ACTIVITY RECOMMENDED BY A DOCTOR?
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Yes
No
DO YOU FEEL PAIN IN YOUR CHEST WHEN YOU PERFORM PHYSICAL ACTIVITY?
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Yes
No
IN THE PAST MONTH, HAVE YOU HAD CHEST PAIN WHEN YOU WERE NOT PERFORMING ANY PHYSICAL ACTIVITY?
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Yes
No
DO YOU LOSE YOUR BALANCE BECAUSE OF DIZZINESS OR DO YOU EVER LOSE CONSCIOUSNESS?
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Yes
No
DO YOU HAVE A BONE OR JOINT PROBLEM THAT COULD BE MADE WORSE BY A CHANGE IN YOUR PHYSICAL ACTIVITY?
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Yes
No
IS YOUR DOCTOR CURRENTLY PRESCRIBING ANY MEDICATION FOR YOUR BLOOD PRESSURE OR FOR A HEART CONDITION?
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Yes
No
DO YOU KNOW OF ANY OTHER REASON WHY YOU SHOULD NOT ENGAGE IN PHYSICAL ACTIVITY?
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Yes
No
IF YOU HAVE ANSWERED YES TO ONE OR MORE OF THE ABOVE QUESTIONS, CONSULT YOUR DOCTOR BEFORE ENGAGING IN PHYSICAL ACTIVITY. TELL YOUR DOCTOR WHICH QUESTIONS YOU ANSWERED YES TO. AFTER MEDICAL EVALUATION, SEEK ADVICE FROM YOUR DOCTOR ON WHAT TYPE OF ACTIVITY IS SUITABLE FOR YOUR CURRENT CONDITION.
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I understand
Medical History & Background information
Medical
HAVE YOU EVER HAD ANY INJURIES OR CHRONIC PAIN?
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Yes
No
IF YES, PLEASE EXPLAIN.
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HAVE YOU EVER HAD ANY SURGERIES?
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Yes
No
IF YES, PLEASE EXPLAIN.
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HAS A MEDICAL DOCTOR EVER DIAGNOSED YOU WITH A CHRONIC DISEASE, SUCH AS HEART DISEASE, HYPERTENSION, HIGH CHOLESTEROL, OR DIABETES?
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Yes
No
IF YES, PLEASE EXPLAIN.
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ARE YOU CURRENTLY TAKING ANY MEDICATION?
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Yes
No
IF YES, PLEASE EXPLAIN.
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Exercise
When was the last time you exercised 3-4 days/week consistently?
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I currently work out that often
It's been a few months
It's been a few years
I've never worked out that often
It's complicated
When did you first start thinking about getting in shape?
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What roadblocks have been in your way in the past?
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List 3 areas where you would like to improve your strength.
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Occupational
WHAT IS YOUR CURRENT OCCUPATION?
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DOES YOUR OCCUPATION REQUIRE EXTENDED PERIODS OF SITTING?
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Yes
No
DOES YOUR OCCUPATION REQUIRE REPETITIVE MOVEMENTS?
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Yes
No
IF YES, PLEASE EXPLAIN.
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DOES YOUR OCCUPATION CAUSE YOU MENTAL STRESS?
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Yes
No
IF YES, PLEASE EXPLAIN.
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Recreational
DO YOU PARTAKE IN ANY RECREATIONAL PHYSICAL ACTIVITIES? GOLF, RUNNING, HIKING, ETC.
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Yes
No
IF YES, PLEASE SHARE WHICH ONES.
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How often, to what level, etc.
DO YOU HAVE ANY ADDITIONAL HOBBIES? READING, VIDEO GAMES, ETC.
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Yes
No
IF YES, PLEASE SHARE.
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Nutrition
On a scale of 1-10, how would you rate your nutrition? (1=very poor, 10=excellent)
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1
2
3
4
5
6
7
8
9
10
Do you ever eat minimally throughout the day and binge at night?
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Frequently
Sometimes
Rarely
Never
How many glasses of water do you typically drink each day?
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1-3 glasses
4-5 glasses
6-8 glasses
9+
Do you ever eat past the point of fullness?
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Frequently
Sometimes
Rarely
Never
List 3 areas of your nutrition you would like to improve.
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Goals/motivators
What are your big picture goals for one year from now?
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What is the big picture motivator(s) for improving your health? What is your 'why'?
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Are there any obstacles that could impede your progress towards achieving your goals?
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What is the biggest thing you need from us to help you along your journey?
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Is there anything else you would like to tell us about yourself? (Feel free to share anything serious, funny, interesting, or unique).
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ADDITIONAL INFORMATION
IS THERE ANYTHING ELSE YOU THINK WE MAY NEED TO KNOW THAT MAY AFFECT YOUR ABILITY TO TRAIN. (THIS IS OF COURSE IN TOTAL CONFIDENCE).
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Client Agreement
I HAVE AGREED TO UNDERTAKE IN A PROGRAM OF PHYSICAL EXERCISE UNDER THE INSTRUCTION OF BRETT HENDERSON FROM WORTH THE WORK FITNESS. TRAINING MAY INCLUDE, BUT IS NOT LIMITED TO, WEIGHT AND/OR RESISTANCE TRAINING, CARDIOVASCULAR TRAINING, AND FLOOR EXERCISES. BRETT FROM WORTH THE WORK FITNESS AGREES TO INSTRUCT AND TRAIN ME REMOTELY. I REALIZE THAT A LARGE PORTION OF MY SUCCESS WILL BE BASED ON MY COMMITMENT TO FOLLOW INSTRUCTION, CHANGING MY LIFESTYLE, AND MY ATTITUDE TOWARDS THE FITNESS PROGRAM. UNFORTUNATELY, WORTH THE WORK FITNESS CANNOT GUARANTEE RESULTS, BUT MY WILLINGNESS TO WORK HARD WILL IMPROVE THE OPPORTUNITY OF SUCCESS. I HAVE READ THE ABOVE POLICY AND AGREE TO ITS TERMS AS IT APPLIES TO MY PERSONAL TRAINING MEMBERSHIP.
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I agree
BY CLICKING ‘I AGREE’ & SUBMITTING THIS COMPLETED FORM, YOU CONFIRM THAT YOU HAVE READ, UNDERSTOOD AND COMPLETED THE PAR QUESTIONNAIRE AND ANSWERED ALL QUESTIONS TRUTHFULLY, TO THE BEST OF YOUR KNOWLEDGE.
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I agree
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