Online Questionnaire

PAR-Q Form

Please complete and submit at least 2 days prior to your first scheduled session.

All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to helping your trainer develop a program that addresses your needs, goals, and is safe and effective.

Name (required):

Date of Birth // Age:

Address:

City: State: Zipcode:

Phone (home): Phone (office): Fax:

Address Email (required):

Occupation:

Emergency Contact: Relationship:

Phone number:

Physician's Name: Physician's Phone:

Physician's Address:

City: State: Zipcode:

Your personal trainer will send information and seek clearance and instruction regarding your physical exercise program to your physician unless you request otherwise.

History

Please mark YES or NO to the following:

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? Yes No 

Do you frequently have pains in your chest when you perform physical activity? Yes No 

Have you had chest pain when you were not doing physical activity? Yes No 

Do you lose your balance due to dizziness or do you ever lose consciousness? Yes No 

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? Yes No 

Are you pregnant now or have given birth within the last 6 months? Yes No 

Have you had a recent surgery? Yes No 

If you have marked YES to any of the above, please elaborate below:

Do you take any medications, either prescription or non-prescription, on a regular basis?Yes No 

What is the medication for?

How does this medication affect your ability to exercise or achieve your fitness goals?

Life style Related Questions:

1) Do you smoke? Yes No 

If yes, how many per day?

2) Do you drink alcohol? Yes No 

If yes, how many glasses per week?

3) How many hours do you regularly sleep at night?

4) Describe your job:  Sedentary Active Physically Demanding

5) Does your job require travel? Yes No 

6) On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)?

7) List your 3 biggest sources of stress:

a) b) c)

8) Do you regularly utilize the services of a massage therapist? Yes No 

9) Is anyone in your family overweight?  Mother Father Sibling Grandparent

10) Were you overweight as a child? Yes No 

If yes, at what age?  0-5 5-10 10-15 15-20

Life style Related Questions:

1) When were you in the best shape of your life?

2) Have you been exercising for the past 3 months? Yes No 

3) When did you first start thinking about getting in shape?

4) What, if anything, stopped you in the past?

5) One a scale of 1-10, how would you rate your present fitness level (1=Worst, 10=Best)?

Nutrition Related Questions:

1) On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?

2) How many times a day do you usually eat (including snacks)?

3) Do you skip meals? Yes No 

4) Do you eat breakfast? Yes No 

5) Do you eat late at night?  Often Sometimes Rarely Never

6) What activities do you engage in while eating? (TV, reading, etc)

7) How many glasses of water do you consume daily?

8) Do you feel drops in your energy levels throughout the day? Yes No 

If yes, when?

9) Do you know how many calories you eat per day? Yes No 

If yes, how many?

10) Are you currently or have you ever taken a multivitamin or any other food supplements? Yes No 

If yes, please list the supplements:

11) At work or school, do you usually:  Eat out Bring food

12) How many times per week do you eat out?

13) Do you do your own grocery shopping? Yes No 

14) Do you do your own cooking? Yes No 

15) Besides hunger, what other reason(s) do you eat?

 Boredom Social Stressed Tired Depressed Happy Nervous

16) Do you eat past the point of fullness?  Often Sometimes Rarely Never

17) Do you eat foods high in fat and sugar?  Often Sometimes Rarely Never

18) List 3 areas of your Nutrition you would like to improve:

a) b) c)

19) Would you like nutritional education or assistance from a professional coach? Yes No 

Exercise Related Questions:

Skip to the next section if you are presently inactive.

1) How often do you take part in physical exercise?

 1-2x/week 3-4x/week 5-7x/week More

2) If your participation is lower than you would like it to be, what are the reasons?

 Lack of Interest Illness/Injury Lack of Time Other

3) For how long have you been consistently physically active?

4) What activities are you presently involved in?

Cardio &/or Sports:

Frequency/Week: Average Length: Difficultly:

Is cardio conditioning an area that you would like us to help you with? Yes No 

Strength Training:

Frequency/Week: Average Length: Difficultly:

List Exercises:

Would you like some assistance with your muscle conditioning program? Yes No 

Stretching:

Frequency/Week: Average Length: Difficultly:

Would you appreciate some help with a stretching program? Yes No 

5) Please check all the activities that interest you:

 Group Fitness Classes Snowshoeing Football Private Personal Training Cross Country Skiing Soccer  Partner Training Hiking Swimming  Boxing workouts Golf Tennis  Indoor Cycling Basketball Triathlon  Pilates/Yoga Baseball Volleyball  Running Programs Rockclimbing  Kayaking Walking Programs  Skiing/Snowboarding White Water Rafting

Developing your Fitness Program:

1) Please check how/when you prefer to exercise:

a)  Large Groups Small Groups Alone Combination

b)  Morning Afternoon Evening

2) Realistically, how often a week would you like to exercise?

3) Realistically, how much time would you like to spend during each exercise session?

4) Based on your schedule and our facility location, where will most workouts take place?

 AB Performance Club Home Another Gym Outside Work Gym

5) Based on your commitment, how often would you like to see a trainer to help you achieve your goals?

 3x/week 2x/week 1x/week 1x/two weeks 1x/month Other:

6) What are the best days during the week for you to commit to your exercise program?

 M T W T F S S

7) If you could design your own exercise program, what would an ideal training week look like to you? Please be specific. List your favorite activities, rest days, time spent, etc.

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Goal Setting:

How can we best help you? Please check that which applies.

 Lose Body Fat Develop Muscle Tone Rehabilitate an Injury Nutrition Education Start an Exercise Program Design a more advanced program Safety Sports Specific Training Increase Muscle Size Fun Motivation

Other:

In order to increase your chances of being successful at achieving your goals, a certain protocol should be followed. Please ensure all your goals are ‘SMART’.

  • S= Specific (Provide details, how long, how much etc.)
  • M= Measurable (How will you measure whether you’ve reached your goals)
  • A= Attainable (Be realistic, set smaller goals)
  • R = Rewards-Based (Attach a reward to each goal)
  • T = Time Frame (Set specific dates for goals)

1) Please list in order of priority, the fitness goals you would like to achieve in the next 3-12 months?

a)
b)
c)

2) How important is it for you to achieve these goals?

 Very Semi Not Very

3) How long have you been thinking about achieving these goals?

4) How will you feel once you’ve achieved these goals? Be specific.

5) Where do you rate health in your life?

 Low Priority Medium Priority High Priority

6) How committed are you to achieving your fitness goals?

 Very Semi Not Very

7) What do you think is the most important thing we at Atlantic Beach Performance can do to help you achieve your fitness goals?

8) Outline what you feel are the obstacles or your potential actions, behaviors, or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise, etc.).

9) Outline 3 methods that you plan to use to overcome these obstacles:

a) b) c)

Miscellaneous Questions:

1) How did you hear about us? Please check applicable source.

 Brochure Yellow Pages Website Drop-in

 Word of Mouth Referral - Who?

 Newspaper/Magazine Column or Ad – Which one?

 Flier in local business – Where?

 Chamber of Commerce/Networking Event Other

2) Why did you choose to train with Atlantic Beach Performance instead of another organization? Please check that which applies.

 Location Personal Trainers Cost Customer Service Word of Mouth Referral Programs You heard we were the best You know we are going to produce results  Other

3) How far do you live from our training studio?

4) Which newspaper(s) do you read?

5) Which radio station(s) do you listen to?

6) Which local magazine(s) do you read?

7) Which local morning TV show do you watch?

8) What would cause you to discontinue training with us?

WAIT!!!

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>>PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT

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And be sure to bring it with you to your appointment.

Atlantic Beach Performance - Fitness Studio