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Fit Little Biscuit PT PARQ
Personal Training Physical Activity Readiness Questionnaire
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YOUR PERSONAL DETAILS
Client Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Address
*
Your answer
Email
*
Your answer
Phone
*
Your answer
EMERGENCY CONTACT DETAILS
Name
*
Your answer
Phone
*
Your answer
YOUR HEALTH GOALS
How would you describe your general health and fitness?
Your answer
What are your main reasons for starting a fitness programme?
General conditioning
Weight / Fat loss
Stress Management
Improve self-esteem / Boost mood
Muscular Strength
Aerobic Fitness
Flexibility
Endurance
Other:
Do you have a specific goal in mind?
Your answer
Have you ever done any structured exercise?
Yes
No
Clear selection
If 'Yes' what did you do?
Your answer
What would you say are the main barriers preventing you from exercising?
Lack of facilities
No motivation
Injury / illness
Unfit
Lack of knowledge
Family
Work
Appearance
No time
DIET AND NUTRITION
On a scale of 1-10 (1 being poor and 10 being excellent) how would you assess the quality of your eating habits?
Your answer
Would like some help or advice in regards to your eating habits?
Yes
No
Clear selection
MEDICAL INFORMATION
BEFORE STARTING A FITNESS PROGRAMME:
Please read each question carefully and answer honestly by indicating YES or NO.
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
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Yes
No
Do you feel pain in your chest when you do physical activity?
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Yes
No
In the past month, have you had a chest pain when you were not doing physical activity?
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Yes
No
Is your doctor currently prescribing medication for your blood pressure or heart condition?
*
Yes
No
Do you lose balance because of dizziness or do you ever lose consciousness?
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Yes
No
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?
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Yes
No
Are you currently receiving treatment (for example, physiotherapy) for any bone or joint problems?
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Yes
No
Are you pregnant, postpartum or breastfeeding?
*
Yes
No
Have you had a major illness or injury in the last 5 years?
Yes
No
Clear selection
Are you receiving treatment for any diagnosed medical condition?
Yes
No
Clear selection
Are you taking any prescription medication?
Yes
No
Clear selection
If you answered 'YES' to any of the questions in this section please give details of medication or treatment you are receiving. It may be necessary to consult with your doctor to clarify that it is safe for you to become physically active at this current time.
Your answer
If you answered NO to ALL of the questions:
It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levels.
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.
SIGNATURE: please retype your full name in lieu of providing an electronic signature
*
Your answer
Date:
*
MM
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DD
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YYYY
NOTE:
This PARQ becomes invalid should any of your answers to any of these questions change.
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