PAR-Q | Mental | Lifestyle QuestionnairePlease enable JavaScript in your browser to complete this form.Name *FirstLastLayoutEmail *Birthdate *Height *Phone *Age *Weight *PAR-Q Health QuestionnaireLayoutHas your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *YesNoDo you have a bone or joint problem that could be made worse by a change in your physical activity? *YesNoIn the past month, have you had chest pain when performing/ not performing physical activity? *YesNoDo you feel pain in your chest when you perform physical activity? *YesNoDo you lose your balance because of dizziness or ever lose consciousness? *YesNoIs your doctor currently prescribing any medication for your blood pressure or for a heart condition? *YesNoE-Signature *Clear SignatureIf you have answered "Yes" to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered "Yes" to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. By signing above, you affirm that you do not have any health issues requiring a physician's evaluation and are able to physically participate in exercise.Mental | Psychological QuestionnaireLayoutWhat are you wishing to do and accomplish by working together? *What do you see as obstacles to achieving your goals? *What has made you successful up to this point in life? *How important is mindset to your success and goal achievement? *Select oneUselessNot ImportantIndifferentImportantVery ImportantWhat do you need most from me as your coach to help you achieve these goals? *What are the outcomes/benefits you will receive from these goals and why are they important to you? *What is your plan of action when faced with an obstacle? *What has most held you back from achieving your goals? *You go to the gym (or exercise) to train physically, but what do you do to train your mindset? *Lifestyle QuestionnaireLayoutWhat is your occupation? *How do you spend the majority of your time at work? *How would you consider your current bodyweight? *How would you describe your current activity level? *Have you ever had personal training/coaching before? *Do you participate in any sports? *How many meals do you eat each day? *How big would you say your meals are? *Are you currently on a diet? *On average how many portions of vegtables do you eat per day? *How many hours do you work per week? *How would you characterize your life? *What does your typical day look like? *How would you rate your present level of fitness? *Do you currently exercise? *How much time will you have to exercise? *What times do you normally eat? *Do you take supplements? *On average how many portions of fruit do you eat each day? *How much water do you drink each day? *CONTROLLABLE DIETARY HEALTH RISK FACTORSLayoutDo You Drink Soda? *YesNoDo You Eat Sweets? Eg. Ice Cream, Candy, or Sugary Treats *YesNoDo You Eat Red Meat? *YesNoDo You Smoke Tobacco? *YesNoDo You Drink Alcohol? *YesNoDo You Drink Coffee? *YesNoDo You Consume High Amounts of Salty Foods? Eg. Chips, Fast Food *YesNoDo You Eat Fried Foods? *YesNoDo You Consume Dairy Products? *YesNoSubmit
