PAR-Q - Paradise Personal Trainer

Paradise Personal Trainer – Client Health Forms

Client Health & Fitness Forms — Please complete both forms before your first session

PAR-Q & YOU

Physical Activity Readiness

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start.

If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 and not used to being very active, check with your doctor. Please read each question carefully and answer honestly.

Revised 2002 · © Canadian Society for Exercise Physiology

Seven Questions

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes No

Do you feel pain in your chest when you do physical activity?

Yes No

In the past month, have you had chest pain when you were not doing physical activity?

Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes No

Do you have a bone or joint problem (e.g., back, knee, or hip) that could be made worse by a change in your physical activity?

Yes No

Is your doctor currently prescribing drugs for your blood pressure or heart condition (e.g., water pills)?

Yes No

Do you know of any other reason why you should not do physical activity?

Yes No

⚠ You answered YES to one or more questions. Talk with your doctor by phone or in person before you start becoming much more physically active or before a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.

You may be able to do any activity you want — as long as you start slowly and build up gradually.
Find out which community programs are safe and helpful for you.

✓ You answered NO to all questions. You can be reasonably sure that you can start becoming much more physically active — begin slowly and build up gradually. This is the safest and easiest way to go.

Client Declaration & Signature

“I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.”

Full Name *

Date *

Signature (draw below) *

Draw your signature above with mouse or touch

Parent / Guardian Signature (if under 18)

Witness

This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.
© Canadian Society for Exercise Physiology · www.csep.ca/forms

PAR-Q Submitted!

Thank you. Your form has been sent to Paradise Personal Trainer.
Please also complete the Health Screening Questionnaire.

Health Screening Questionnaire

Form 2.2

This questionnaire identifies adults for whom physical activity might be inappropriate or adults who should consult a physician before beginning a regular physical activity program.

Section 1 — Personal & Emergency Contact

Full Name *

Date of Birth *

Address

Phone

Physician’s Name

Email Address

Height

Weight

Today’s Date

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Section 2 — General Medical History

Please check all conditions you have experienced.

Heart History

Heart attack Cardiac rhythm disturbance Heart surgery Heart valve disease Cardiac catheterization Heart failure Coronary angioplasty (PTCA) Heart transplantation Cardiac pacemaker / implantable defibrillator Congenital heart disease

Symptoms

I experience chest discomfort with exertion. I experience unreasonable shortness of breath at any time. I experience dizziness, fainting, or blackouts. I take heart medications.

Additional Health Issues

I have diabetes (type 1 or type 2). I have asthma or other lung disease (e.g., emphysema). I have burning or cramping sensations in my lower legs with minimal physical activity. I have joint problems (e.g., arthritis) that limit my physical activity. I have concerns about the safety of exercise. I take prescription medications. I am pregnant.

Section 3 — Risk-Factor Assessment

Risk Factors for Coronary Heart Disease — check all that apply.

I am a man ≥ 45 years old. I am a woman ≥ 55 years old. I smoke or quit smoking within the previous 6 months. My blood pressure is ≥ 140 or ≥ 90 mmHg. My total cholesterol is ≥ 200 mg·dl¹, or LDL-C ≥ 130, or HDL-C < 40 mg·dl¹. I have prediabetes. I have a close male blood relative (father/brother) with heart attack or surgery before age 55, or female relative (mother/sister) before age 65. I am physically inactive (less than 30 min moderate activity, 3 days/week). My BMI is ≥ 30 kg·m² or waist > 40 in. (men) or > 35 in. (women).

Section 4 — Medications

Are you currently taking any medication?

Yes No

List all prescribed medications and frequency (Daily or PRN)

Are there any you do not take as prescribed? Please explain.

Section 5 — Physical Activity Patterns & Objectives

Describe your current weekly exercise (type, frequency, intensity, duration)

Specific goals for your exercise program

Please Note Please inform your fitness professional immediately of any changes that occur in your health status.

Patient Information Release & Signature

If you have answered yes to questions indicating significant cardiac, pulmonary, metabolic, or orthopedic problems that may be exacerbated with exercise, you agree it is permissible for us to contact your physician regarding your health status in compliance with the Health Information Portability and Accountability Act of 1996 (HIPAA).

Client Signature *

Draw your signature with mouse or touch

Date *
Fitness Staff Signature Staff Date

To be completed by Fitness Professional

AHA and ACSM Risk Stratification:

Low Moderate High

Physician Consent:

Yes No

Adapted from: Howley & Thompson, Fitness Professional’s Handbook, 6th ed. (Human Kinetics, 2012). Adapted from American College of Sports Medicine 2010.

All Forms Submitted!

Thank you! Both forms have been received by Paradise Personal Trainer.
We’ll be in touch soon to schedule your first session.