Your Personal Details

Your name:

Your DoB:

Your Address:

Your email

Phone

Emergency Contact Details

Name:

Address:

Email

Phone

Your Health Goals

What health goals would you like to achieve in the next 3 months?



Name 3 things that you could do to improve your health?

What are your main reasons for starting a fitness programme?

General conditioningWeight/fat lossStress managementMuscular strengthAerobic fitnessFlexibilityNo timeAppearanceImprove self-esteem

How would you describe your general health and fitness?

Have you ever done any structured exercise?

YesNo


If 'yes', what did you do?

What type of exercise do you enjoy the most?



What type of exercise do you dislike the most?

What would you say are your main barriers to exercising?

Lack of facilitiesInjury/illnessLack of knowledgeNo motivationUnfitFamilyNo timeAppearanceWork

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?

Would you like any help or advice in changing the quality of your eating habits?

YesNo

Do you do any of the following:

Drink alcohol?

YesNo

Smoke?

YesNo

If you answered yes, would you like any help or advice to change these habits?

YesNo

Medical History

Have you had a major illness or injury in the last 5 years?

YesNo


If yes, please give details:

Are you receiving treatment for any diagnosed medical condition?

YesNo


If yes, please give details:

Are you taking any prescription medication?

YesNo

If yes, please give details:

Please indicate if you have ever experienced any of the following symptoms. Do you:

Ever get unusually short of breath with very light exertion?Ever have pain, pressure, heaviness or tightness in the chest area?Regularly have unexplained pain in the abdomen, shoulders or arms?

Please indicate if you have ever experienced any of the following symptoms. Do you:

Ever have severe dizzy spells or episodes of fainting?Regularly get lower leg pain during walking that is relieved by rest?Ever experience palpitations or irregular heartbeats?Are you currently pregnant or have you given birth in the last 6 months?

Structural Health

Please provide details of any aches, pains or problem areas and whereabouts these are located. Please also mention if any of these areas are aggravated by exercise and if you are receiving any treatment for structural problems:

Please indicate if there are any other health problems you suffer from which are not already mentioned:

I can confirm that I have answered all questions honestly and that the information given is correct

Yes, I confirm

Note: This PAR Q becomes invalid should your condition change.