New Client/PARQ FormThis is a new client form and physical activity readiness questionnaire. Please fill this out before our first session together. I can’t wait to work with you! Date * MM DD YYYY Name * First Name Last Name Email * Phone (###) ### #### Age * Birthdate * MM DD YYYY Height Weight Physical Activity Readiness Date of last physical MM DD YYYY Has your doctor ever said that you have a heart condition and recommended only medically supervised activity? Yes No Have you had chest pain when you were not doing physical activity? Yes No Do you lose your balance due to dizziness or do you ever lose consciousness? Yes No Have you experienced any shortness of breath, heart murmur, or heart racing? Yes No Are you pregnant now or have you given birth in the last six months? Yes No Have you had a recent surgery? Yes No If you marked YES to any of the above please elaborate below. Cardiovascular + Health History Check any risk factors or information on the following: Blood Pressure Cholesterol Diabetes Heart Disease Do you smoke cigarettes? How much alcohol a week do you drink? What prescriptions are you presently taking and why? ORTHOPAEDIC HISTORY Have you ever broken a bone? If yes, where and when? Check any problem areas. Low back Upper back Neck Shoulders Elbows Wrists Pelvis Knees Ankle Foot EXERCISE HISTORY and GOALS What exercise or organized sports have you done in the past? Are you currently involved in a regular exercise program, describe your typical exercise regimen? * (weights, yoga, cardio, how long per workout, how many times a week) What are your goals in training now, any particular activity or exercise that you have always wanted to do? * (pull-up, handstand, max bench press, compete in a triathlon) How many times a week can you work out? * What hinders your workouts now and in the past? PRESENT LIFESTYLE Occupation Is it sedentary? or active? or in the middle? Stress level at work 1-10, episodic, or continual Do you manage stress well? yes no Sleep quality and amount Amount of air travel Commuting time Do you experience anxiety or depression? NUTRITION AND WEIGHT GOALS What is a typical daily diet for you? breakfast, lunch, dinner Have you had any history of eating disorders? (anorexia, bulimia, emotional eating) Has there been more than a 5 lb. fluctuation of weight in the past year? Is there anything you would like to change about your body? FITNESS PARTICIPATION AGREEMENT I have voluntarily chosen to participate in physical activity. I have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent or restrict me from participation in any exercise program given remotely online or in-person. I understand that by signing this agreement that I hereby waive and release Ariana Rabinovitch in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation. I affirm that I have read and understood this document and I wish to participate in physical activities. Signed * Date MM DD YYYY Thank you!
