New Client Induction Form Full Name(required) Address(required) Email(required) Date of Birth(required) Phone Emergency Contact Information Emergency Contact Full Name(required) Emergency Contact Telephone(required) Emergency Contact Address Emergency Contact Relationship Physical Activity Readiness Questionnaire (PAR-Q) Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor?(required) Yes No Do you feel pain in your chest when you do physical activity?(required) Yes No In the past month, have you had chest pain when you were not doing physical activity?(required) Yes No Do you lose your balance because of dizziness or do you ever lose consciousness?(required) Yes No 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?(required) Yes No Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?(required) Yes No Do you know of any other reason why you should not do physical activity?(required) Yes No Health History Questionnaire Are you taking any medications, supplements, or drugs? if so, please list medication, dose, and reason. Does your physician know you are participating in this exercise program? Yes No Describe any physical activity you do somewhat regularly Do you now have, or have you had in the past: History of heart problems, chest pain, or stroke? Yes No Elevated blood pressure? Yes No Any chronic illness or condition? Yes No Difficulty with physical exercise? Yes No Advice from physician not to exercise? Yes No Recent surgery (last 12 months)? Yes No Pregnancy (now or within last 3 months)? Yes No History of breathing or lung problems? Yes No Muscle, joint, or back disorder, or any previous injury still affecting you? Yes No Diabetes or metabolic syndrome? Yes No Thyroid condition? Yes No Cigarette smoking habit? Yes No Obesity (body mass index (BMI) >= 30kg/m^2) Yes No Elevated blood cholesterol? Yes No History of heart problems in immediate family? Yes No Hernia, or any condition that may be aggravated by lifting weights or other physical activity? Yes No Exercise History Questionnaire Please rate your exercise level on a scale of 1 – 5 (5 indicating very strenuous) 1 2 3 4 5 Do you have any negative feelings toward, or have you had any bad experiences with, physical-activity programs? Yes No Do you have any negative feelings toward, or have you had any bad experiences with, fitness testing and evaluation? Yes No Rate yourself on a scale of 1 – 5 (1 indicating the lowest value and 5 the highest) Characterize your present athletic ability 1 2 3 4 5 Characterize your present cardiovascular capacity 1 2 3 4 5 Characterize your present muscular capacity 1 2 3 4 5 Characterize your present flexibility capacity 1 2 3 4 5 How many minutes a day are you willing to devote to exercise? How many days per week are you willing to devote to exercise? How long have you been exercising regularly? Can you exercise during your work day? Yes No Would an exercise program interfere with your job? Yes No Would an exercise program benefit your job? Yes No What types of exercise interest you? Walking Cycling Rowing Stationary biking Stair climbing Jogging Traditional aerobic Elliptical striding Swimming Strength training Racquet sports Yoga/Pilates Other Activities If "Other Activities", please describe below… What are you goals? (check all that apply) Improve cardiovascular fitness Lose weight/body fat Increase muscle mass Correct muscular/postural imabalances Reshape or tone my body Improve performance for a specific sport Improve moods and ability to cope with stress Improve flexibility Increase strength Increase energy level Feel better Increase enjoyment Social interaction Other If "Other", please describe below… Submit Δ Share this:TwitterFacebookLike this:Like Loading...
Robyn J. Fitness 