Health and Lifestyle Questionnaire
Name: _______________________________________________________________________________ Date of Birth: __________________________________________________________________________ Address: ______________________________________________________________________________ Phone: _______________________________________________________________________________ E-mail: _______________________________________________________________________________ Preferred method of contact: _____________________________________________________________ Emergency contact name: _______________________________________________________________ Relationship: __________________________________________________________________________ Phone number: _________________________________________________________________________
PAR-Q FORM Please answer ‘YES’ or ‘NO’ to the following: Has your doctor ever said you have a heart condition and recommended only medically supervised physical activity? Do you frequently have pains in your chest when you perform physical activity? Have you had chest pain when you were not doing physical activity? Do you lose your balance due to dizziness or do you ever lose consciousness? 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 or neck problems, asthma, etc.) Are you pregnant now or have you given birth in the last six months? Have you had surgery in the last six months? If you have marked ‘YES’ to any of the above, please elaborate below: _____________________________________________________________________________________________ _____________________________________________________________________________________________...
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