PAR-Q Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Are you: * Married Single Divorced Widowed Weight * Height * Occupation * How did you hear about us? * Date of last physical * Past or current medical conditions requiring treatment * Medication(s) presently using including dosage and frequecy * Do you currently have any joint/ bone issues? * Have you had any orthopedic surgeries? * Do you ever experience chest pain through normal daily activity? * Do you experience balance issues and/ or episodes of dizziness? * Are you a current cigarette smoker? * How often do you consume alcohol? * Do you have good eating habits? * Do you drink water throughout the day? * Are you currently exercising regularly? * Yes No Have you trained with a personal trainer before? * Yes No Which of the following best fits with your goals? * Select all that apply Improved health Improved endurance/ stamina Increased strength Increased muscle mass Increased muscle tone Fat loss How many days per week are you looking to train? * Which days of the week are you looking to train? * Select all that apply Monday Tuesday Wednesday Thursday Friday Saturday Sunday When is your best availability? * Select all that apply Morning Mid-day Afternoon Evening All apply Thank you! We will go over your form shortly and reach out to you to schedule a consultation to go over everything in more detail to figure out how we can best help you reach your goals. We look forward to speaking with you. -Jon Paul Owner/ Head Trainer
