Fillable Form Here - Fitness for Impact

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FITNESS FOR IMPACT
Kevin Hsu – Owner & Personal Trainer
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)
(This health form must be completed by anyone participating in any type of training with Fitness for Impact)
BASIC INFORMATION
Name: Click here to enter text.
Date: Click here to enter a date.
Phone: Click here to enter text.
Home
Cell
E-mail: Click here to enter text.
Preferred method of contact: Click here to enter text. (E-mail, Text, Cell etc.)
DOB: Click here to enter a date.
Age: Click here to enter text.
Height: Click here to enter text.
Weight: Click here to enter text.
Work
EMERGENCY CONTACT INFORMATION
Name: Click here to enter text.
Address: Click here to enter text.
Phone: Click here to enter text.
Relationship: Click here to enter text.
Home
Cell
Work
PHYSICIAN INFORMATION
Name: Click here to enter text.
Address: Click here to enter text.
Phone: Click here to enter text.
Specialization: Click here to enter text.
Home
Cell
Work
GENERAL & MEDICAL QUESTIONNAIRE
1. What is your current occupation? Click here to enter text.
2. Does your occupation require extended periods of sitting?
Yes
No
3. Does your occupation require extended period of repetitive movements?
Yes
No
If yes, please explain: Click here to enter text.
4. Are you currently under a doctor’s care?
Yes
No
If yes, please explain: Click here to enter text.
5. Has your doctor ever said that you have a heart condition and that you should only perform
physical activity recommended by a doctor ?
Yes
No
6. Do you feel pain in your chest when you perform physical activity?
Yes
No
7. In the past month, have you had chest pain when you were not performing any physical
activity?
Yes
No
8. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
9. Do you have a bone or joint problem that could be made worse by a change in physical
activity?
Yes
No
10. Is your doctor currently prescribing any medication for your blood pressure or for a heart
condition?
Yes
No
11. Are you currently taking any other type of medication?
Yes
No
If yes, please include medication and reason for taking them: Click here to enter text.
12. Have you been recently hospitalized?
Yes
No
If yes, please explain: Click here to enter text.
13. Do you smoke?
Yes
No
14. Are you pregnant?
Yes
No
15. Do you drink alcohol more than 3 times per week?
Yes
No
16. Is your stress level high?
Yes
No
17.
Do you have any of the following?
 High Blood Pressure
Yes
No
 High Cholesterol
Yes
No
 Diabetes
Yes
No
18. Do you have parents or siblings who have had any of the following prior to the age of 55?
 Heart Attack
Yes
No
 Stroke
Yes
No
 High Blood Pressure
Yes
No
 High Cholesterol
Yes
No
 Known Heart Disease
Yes
No
 Rheumatic Heart Disease
Yes
No
 Heart Murmur
Yes
No
 Chest pain with exertion
Yes
No
 Irregular Heartbeat or Palpitation
Yes
No
 Lightheadedness
Yes
No
 Unusual shortness of breath
Yes
No
 Cramping in legs or feet
Yes
No
 Emphysema
Yes
No
 Other Metabolic Disorder (thyroid, kidney, etc)
Yes
No
 Epilepsy
Yes
No
 Asthma
Yes
No
 Back Pain (upper, middle, and/or lower)
Yes
No
 Other Joint Pain
Yes
No
If yes, please explain: Click here to enter text.
 Muscle Pain or Injury
Yes
No
If yes, please explain: Click here to enter text.
MEDICAL CLEARANCE: If you answered YES to any of the above questions or if there are any
physical problems that would possibly impair your partaking in an individualized, vigorous
training program or put you at any risks, you will need to have a Medical Clearance Form
completed by your physician prior to starting your training program.
I, Click here to enter text. , attest to the best of my knowledge that the above information is true
and accurate.
Signature:_______________________
Date:_________________________
Printed Name: _______________________
Witness:________________________
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