Personal Training Questionnaire & PAR-Q+

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Completing this information is necessary prior to your first visit. This information will provide your trainer some valuable information about you, and help in planning your training and/or nutrition program.

Personal Information

First Name*

Last Name*

Email*

Phone*

Age*

Gender*

Height*

Weight*

Physician Name*

Physician Phone*

Emergency Contact Name*

Emergency Contact Phone*

Exercise

What exercise activities do you currently take part in (eg., running, weightifting, group exercise, etc.)?*

How many days per week do you get at least 30 minutes of moderate-intensity exercise?*

On a scale of 1 to 5, how important are the folowing fitness goals to you?
1 - Not really, 2 - Slightly, 3 - Moderately, 4 - Fairly, 5 - Very

Weight Loss*

Muscle Gain*

Flexibility/Mobility*

Overall Wellness*

Nutrition

On a scale of 1 to 5, how important is it for you to improve or maintain your current nutrition goals?*

1 - Not really, 2 - Slightly, 3 - Moderately, 4 - Fairly, 5 - Very

Are you currently following any kind of diet?*

Yes

Which diet and for what reason(s):

Accountability

How many times per week do you intend to train with a personal trainer?*

Do you give your personal trainer consent to touch you in order to guide or direct you through various exercises or assisted stretching techniques?*

Yes

Medical

Please list any past musculoskeletal injuries:*

Please list any past surgeries:*

If you have experienced injuries or surgeries, were they properly rehabilitated, and did you receive clearance from a doctor to return to physical activity?*

Do you have any chronic health conditions (such as, but not limited to, cardiovascular disease, pulmonary disorders, hypertension, diabetes, or cancer)?

Yes

Explain chronic health conditions here:*

Are you on any medications, and if so, have you received clearance from your doctor to take part in physical activity?*

Additional notes:

PAR-Q+: The Physical Activity Readiness Questionnaire for Everyone
The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tel you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.

General Health Questions

1. Has your doctor ever said that you have a heart condition OR high blood pressure?*

Yes, heart condition

Yes, high blood pressure

2. Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*

Yes

3. Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).*

Yes

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

Yes

Please list conditions here:

5. Are you currently taking prescribed medications for a chronic medical condition?*

Yes

Please list condition(s) or medication(s) here:

6. Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.*

Yes

Please list condition(s) here

7. Has your doctor ever said that you should only do medically supervised physical activity?*

Yes

General Health Recommendations

You answered NO to all of the General Health questions above, you are cleared for physical activity.*

Please complete and submit the remainder of the form. Start becoming much more physically active - start slowly and build up gradually. Follow Global Physical Activity Guidelines for your age. You may take part in a health and fitness appraisal. If you are over the age of 45 years and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in the intensity of exercise. If you have any further questions, contact a qualified exercise professional.

I have read and understand these recommendations.

You answered YES to one or more of the General Health questions above. Please continue with the Followup Questions below.*

***DELAY BECOMING ACTIVE IF: You are currently experiencing a temporary illness, such as a cold or fever. It is best to wait until you feel better; You are pregnant. In this case, talk with your health care practitioner, physician, qualified exercise professional, and .or complete the ePARmed-X+ at www. eparmedx.com before becoming more physically active; Your health changes. Answer the next questions of this form and/or take to your health care practitioner, physician, or qualified exercise professional before proceeding with any physical activity program.

I have read and understand these recommendations.

Followup Questions

1. Do you have Arthritis, Osteoporosis, or Back Problems?*

Yes

1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments.)*

Yes

1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis, and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*

Yes

1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*

Yes

2. Do you currently have Cancer of any kind?*

Yes

2a. Does your cancer diagnosis include any of the folowing types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*

Yes

2b. Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*

Yes

3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm?*

Yes

3a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*

Yes

3b. Do you have an irregular heart beat that required medical management? (e.g., atrial fibrillation, premature ventricular contraction)*

Yes

3c. Do you have chronic heart failure?*

Yes

3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*

Yes

4. Do you currently have high blood pressure?*

Yes

4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medication for other treatments.)*

Yes

4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure).*

Yes

5. Do you have any Metabolic Conditions? This includes Type 1Diabetes, Type 2Diabetes, Pre-Diabetes*

Yes

5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?*

Yes

5b. Do you often suggest from signs and symptoms of low blood sugar (hypoglycaemia) following exercise and/or during activities of daily living? Signs of hypoglycaemia may include shakiness, nervousness, unusual irritability, abnormal seating, dizziness or light-headedness, mention confusion, difficulty speaking, weakness, or sleepiness.*

Yes

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*

Yes

5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*

Yes

5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*

Yes

6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer's, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*

Yes

6a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*

Yes

6b. Do you have Down Syndrome AND back problems affecting nerves or muscles?*

Yes

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*

Yes

7a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*

Yes

7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*

Yes

7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*

Yes

7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*

Yes

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*

Yes

8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*

Yes

8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?*

Yes

8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*

Yes

9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event*

Yes

9a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*

Yes

9b. Do you have any impairment in walking or mobility?*

Yes

9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*

Yes

10. Do you have any other medical condition not listed above or do you have two or more medical conditions?*

Yes

10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*

Yes

10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*

Yes

10c. Do you currently live with two or more medical conditions?*

Yes

Please list your medical condition(s) and any related medications here:

Recommendations

You answered NO to all of the Followup Questions about your medical condition. You are ready to become more physically active.*

It is advised that you consult a qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs. You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises; As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week; If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

I have read and understand these recommendations.

You answered YES to one or more of the Followup Questions about your medical condition. You should seek further information before becoming more physically active or engaging in a fitness appraisal.*

You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information. ***DELAY BECOMING MORE ACTIVE IF: You are currently experiencing a temporary illness, such as a cold or fever. It is best to wait until you feel better; You are pregnant, In this case, talk to your health care practitioner, physician, qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active; Your health changes. Talk to your health care practitioner, physician, or qualified exercise professional before continuing with any physical activity program. You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted. The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire, consult your doctor prior to physical activity.

I have read and understand these recommendations.

All persons who have completed the PAR-Q+ must read and check the declaration box below. If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

1, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that ClubWorx may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

I have read and understand this declaration.

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Personal Training Questionnaire & PAR-Q+

Personal Information

Exercise

Nutrition

Accountability

Medical

General Health Questions

General Health Recommendations

Followup Questions

Recommendations

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