Client Health Screening

PAR-Q & PAR-Q+ Intake Form

Please answer every question honestly and completely. This information is used to ensure your training program is safe and effective. All responses are kept strictly confidential.

Personal Information

Full Name *

Date of Birth *

Email Address *

Phone Number

Today's Date *

Emergency Contact Name

Emergency Contact Phone

PAR-Q — Section 1

Physical Activity Readiness Questionnaire

Answer YES, NO, or I DON'T KNOW to each of the following 7 questions. 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 years of age, please consult your doctor before beginning any new activity.

PAR-Q Health Questions

Question 1

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 I Don't Know

Question 2

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

Yes No I Don't Know

Question 3

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

Yes No I Don't Know

Question 4

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

Yes No I Don't Know

Question 5

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?

Yes No I Don't Know

Question 6

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

Yes No I Don't Know

Question 7

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

Yes No I Don't Know

⚠ Medical Clearance Recommended

You answered Yes or I Don't Know to one or more questions. Please consult your physician before beginning any exercise program. Bring a copy of this form to your doctor and ask which activities are safe for you. You may still complete this form — your coach will review your responses before programming begins.

PAR-Q+ — Section 2

Extended Health & Lifestyle Screening

These additional questions help your coach understand your full health picture and design the safest, most effective program for you.

Have you ever been diagnosed with any of the following? (Check all that apply)

Heart disease or heart attack High blood pressure Stroke Type 1 or Type 2 Diabetes Kidney disease Arthritis or osteoporosis Cancer (current or in remission) Chronic respiratory disease (asthma, COPD) Mental health conditions (anxiety, depression) Pregnancy or recent childbirth (within 6 months) None of the above

Lifestyle & Training Goals

Current Fitness Level

Primary Fitness Goal

Days Available to Train Per Week

Equipment Access (Check all that apply)

Commercial gym Home gym Minimal equipment No equipment (bodyweight only)

Current Injuries or Physical Limitations

Current Medications (optional)

Anything Else Your Coach Should Know? (optional)

Consent & Signature

Declaration

Please read and confirm each statement below before submitting.

I confirm that all information provided on this form is accurate and complete to the best of my knowledge.

I understand that this screening does not replace professional medical advice and that I should consult a physician if I have any concerns about my health.

I understand that I am voluntarily participating in a personal training program and that I take responsibility for my own health and safety during exercise.

Digital Signature *

Date Signed

Your information is kept strictly confidential and will only be used by your coach.

Form Submitted Successfully

Thank you — your PAR-Q intake has been received. Your coach will review your responses within 24 hours and reach out to confirm next steps.