Par Q Health Questionnaire

Gender

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date Of Birth

Phone Number

Email Address

Do you have a heart condition?

Yes
No

Do you feel pain in your chest when you exercise?

Yes
No

Do you have high blood pressure?

Yes
No

Have you had a heart attack or bypass operation?

Yes
No

Are you diabetic?

Type I
Type II
No

Do you suffer from asthma or any respiratory conditions?

Yes
No

Do you have any bone or joint problems that could be made worse by a change in your physical activity?

Yes
No

Do you suffer from dizzy spells or fainting?

Yes
No

Do you smoke?

Yes
No

Are you pregnant?

Yes
No

Have you had any operations in the last year?

Yes
No

*If you have answered YES to particular questions I will provide you with a medical clearance form. Talk to your Doctor before you start to exercise. The medical clearance form will ask for advice from your Doctor about any activities that you may or may not be able to participate in.

Daily Activity

How would you describe your level of physical activity?

Sedentary
Active
Quite Active

Hobbies (Please State)

Leisure Activities (Please State)

Moderate Physical Activity

During the last month what types of moderate activity have you engaged in for at least 30 minutes (these could be 3 sessions of 10 mins)?

How frequently did you exercise moderately last month?

What type of exercise did you undertake in?

Cardio Vascular (walking, swimming)
Resistance (gardening, lifting)
Other (Please State)

Other (Please State)

Activity Preferences

What mode of training do you prefer?

Other (Please Specify)

What method of training do you prefer?

Other (Please Specify)

What is your preferred training environment?

Gym
Outdoor
Home
Other (Please Specify)
Competitive
Non-Competitive
Other (Please Specify)

Other (Please Specify)

Nutritional Information

Please provide a brief description of your likes, dislikes and eating habits

What are you exercise goals and aims? (e.g. to complete a 5km charity run)

PSYKO FIT