PAR-Q & Client agreement

About you

First Name *

Last name *

Email Address *

Mobile number *

Date of birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Weight (in Kg) *

Height (in meters) *

Age *

What's your gender? *MaleFemalePrefer not to say

Lifestyle

What's your occupation?

How active is your job?

Health & Behaviour History

Are you pregnant? *YesNo

Have you had a baby in the past 6 months? *YesNo

Are you breastfeeding? *YesNo

Please tell us a bit more about this - how old is your baby? How many times are you breastfeeding daily on average? *

Any complications during/after pregnancy? *

Are you going through perimenopause/menopause? *YesNo

Describe your symptoms and management strategy *

Are you taking HRT or other hormones? *

What's your blood pressure like? *

What's your cholesterol like? *

Have you had any surgeries recently? *

Have you got any injuries that limit your ability to exercise? *

Are you currently on any medications? If so, please tell us a bit about which medications and why *

Do you/have you ever suffered from any mental health conditions, such as depression, anxiety, OCD, stress related etc. *

Do you/have you ever taken medication for these symptoms?

What are your goals?

Physical Activity Readiness Questionnaire (PAR-Q)

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

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

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

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

Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity? *YesNo

Is your doctor currently prescribing medication? (for your blood pressure, heart condition etc?) *YesNo

Do you suffer from Asthma? *YesNo

Do you suffer from Epilepsy? *YesNo

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

If you answered yes to any of the above questions, please comment. *

Signed *In consideration of being able to take part in exercise and physical activity organised by ace lifestyle, I acknowledge that I am physically fit for participating in ace lifestyle activities. I agree to abide by all verbal and written notices regarding safety whilst exercising with ace lifestyle. ace lifestyle shall not be liable for any injury or death I may suffer in these activities.

Signature *

Full name *