Health Questionnaire Health Questionnaire "*" indicates required fields Step 1 of 12 - About You 8% CommentsThis field is for validation purposes and should be left unchanged.About YouAbout This Form PAR-Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of a PAR-Q is a sensible first step to take if you are planning on increasing the amount of physical activity in your life. For most people physical activity should not pose a problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide in answering these questions.The TriNeet Fitness Promise To You When you book me as your Personal Trainer you will receive: A complete workout plan (if required) prepared personally by me. Your training schedule will be based on: Your chosen fitness goals Your chosen training methods Your personal fitness and health level Safe personal training plan based on safe and correct technique(s) Practical teaching experience, over 30 years as an athlete and my qualifications have taught me that this is the only effective way to avoid injuries and achieve your full potential A weekly "feedback and motivate" by phone or email including updates to your exercise schedule as you progress and nutrition tips 100% Respect, patience and support. Today's Date* About YouFirst Name*Last Name*Address* Address Line 1 Address Line 2 City Post Code Home Phone*Mobile PhoneWork PhoneEmail* OccupationHeight*WeightDate of Birth*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Emergency Contact DetailsName*RelationshipAddress* Address Line 1 Address Line 2 City Post Code Home PhoneMobile Phone*Work Phone GP Surgery DetailsName*Telephone Number*Surgery Address* Address Line 1 Address Line 2 City Post Code About Your Exercise HabitsWhat health and fitness goals would you like to achieve in the next 3 months?*i.e. lose 7lbs, start a running programme etcWhat health and fitness goals would you like to achieve over the next 12 months?*Name 3 things you will do in order to improve your health and fitness Improvement 1*Improvement 2Improvement 3Would you like TriNeet Fitness to record your body measurements each month?*This will include measuring parts of your body and taking a body fat %YesNoWhich areas of your body do you want to target?*State all that apply About Your Current FitnessWhat are your main reasons for starting a fitness program?* General Conditioning Stress Management Aerobic Fitness Enjoyment Improve Self-esteem Appearance Weight and Fat loss Muscular Strength Flexibility Social Disease Prevention Other Check All that ApplyIf Other Please Give DetailsHave you ever done any structured exercise?*NoYesIf Yes What Activities Did You Do?Please also state how hard you worked and for how longHow long did you do this for?How many times per week did you complete this type of activity?Did you get the results you've hoped for?NoYesIf Yes, why did you stop?How would you describe your current fitness condition?*Please give details of your current exercise programmes, if applicableWhat types of exercise do you enjoy the most?*What types of exercise do you NOT enjoy?*What would you identify as the main barriers preventing you from exercising in the future?* Procrastination No Time Injury Financial Cost Family Responsibilities Lack of Motivation Lack of Facilities Lack of ability or fitness Lack of relevant knowledge Medical Advice Other Check all that applyIf Other, Please Give DetailsWhat training environments do you enjoy?* Indoors Outdoors Gym Classes Other If Other, Please Give DetailsWhat are your preferred training methods?* Running (How to start a running programme or improve) Resistance Training (Light weights and bodyweight, etc) Circuit Training/Body Conditioning/Strength Work Fitness Walking (mixture of walking and resistance exercises) Pure Cardio (mixture of walking and resistance exercises) Pilates/Yoga/Core style workouts Other Check all that applyIf Other, Please Give DetailsDo you prefer your workout to* Vary each time Remain the same for a short period of time to see progress Your Nutritional NeedsOn a scale of 1-5 how would you assess the quality of your diet?* 1 Very Low 2 3 4 5 High Do you follow a particular diet?* No Vegetarian and Fish Vegetarian Vegan Allergy Elimination Other If Other, Please Give Details*Would you like any advice or support to help you make any changes to the quality of your diet?*YesNoIf you answered Yes to the question above, please state below your 3 goals for doing thisGoal 1*Goal 2Goal 3Have you had your diet analysed before?*YesNoIf you answered Yes above, please give more details*What would you say are your nutritional weaknesses? Over Eating Under Eating Portion Control Chocolate Crisps Alcohol Other If Other, Please Give DetailsPlease list any mineral supplements you currently takeDo you: Skip meals? Eat breakfast? Eat late at night? Check all that apply About Your Lifestyle How many units of alcohol do you drink in a typical week? One unit of alcohol equals: (1/2 pint of a standard beer/lager, 1 small glass of wine, 1 pub measure of a spiritNo. of Units*Do you smoke? Yes No Occasionally If you answered Yes, please indicate the number smoked per day 1-9 10-19 20-39 40+ Would you like help to stop smoking?* Yes No Not applicable How many hours do you regularly sleep?*Describe your job: Sedentary Active Physically Demanding About Your Medical HistoryDo you have any of the following conditions?* Osteoarthritis Rheumatoid arthritis Knee/thigh injury Back pain/injury Wrist/hand injury Ankle/foot injury Swollen joints Shoulder injury Head/neck injury Arm/elbow injury Hip/pelvis injury Nerve damage Bone fracture None of the above Please check all that applyIf you answered Yes to any of the conditions above, please give further details hereAre these injuries aggravated by exercise? If Yes, please give further details hereDo you have any other injuries aggravated by exercise?*NoYesIf Yes, please give further details hereAre you currently receiving physical therapy?*YesNoIf Yes please give further details here About Your Current Medical Condition Based on your answers in this section we may ask your permission to seek your GP's advice before commencement of any exercise programme.Is there a family history of any of the following medical conditions?* Heart Problems Epilepsy Cancer Diabetes Early Menopause Other None of the above Please check all that applyIf Other, Please Give DetailsPlease tick any of the following for which you have been diagnosed or treated by a doctor or a health professional* Asthma Epilepsy High Blood Pressure Diabetes Heart Problems Cancer Other None of the above If Other, Please Give DetailsPlease state if you have taken any of the following medications in the last 6 months* Blood Thinner Epilepsy medication Beta Blockers Anti Depressants Diabetic Medications Diuretics Cancer medications Other None of the above If Other, Please Give DetailsTick the box if you have ever experienced any of the following symptoms. Do you...* Ever get unusually short of breath with very light exertion? Ever have pain, pressure or tightness in the chest area? Regularly have unexplained pain in the abdomen, shoulder or arm? Ever have severe dizzy spells or episodes of fainting? Regularly get lower leg pain during walking that is relieved by rest? Ever feel "skips" palpitations or runs of fast beats in your chest? None of the above Please list any health problems you suffer from, not already mentionedAre you currently pregnant or have you given birth in the last 12 months?*NoYes Declaration I confirm that to the best of my knowledge the information given within this document is correct and I understand that it will be treated with strictest confidence by TriNeet Fitness (and by those acting for and on behalf of TriNeet Fitness) for services that I may wish to engage in now and in the future.Name*Today's Date* Informed ConsentI acknowledge that by submitting this document, I have voluntarily chosen to participate in a program of progressive physical exercise. This can enhance the musculoskeletal and cardio respiratory systems. In signing this document, I acknowledge being informed of possible strenuous nature of the program and the potential for unusual, but possible physiological results including, but not limited to,abnormal blood pressure, fainting, heart attacks or death. I understand that questions about exercise procedures and recommendations are encouraged and welcomed. I have been informed of the need to obtain a doctor's examination and approval prior to the beginning this exercise program. I accept all responsibility for my health and any result of an injury or mishap that may affect my well-being or health in any way. By signing this document, I assume all risk for my health and well-being and hold harmless of any responsibility, the trainer, facility or any persons involved with this program and testing procedures.Name*Today's Date* Final ConfirmationBy submitting this form, I agree to... Inform TriNeet Fitness of any aches, pains or illnesses have I that I have had since the previous session Let TriNeet Fitness know if I need to cancel a session by calling at least 24 hours before the scheduled time During all training sessions I agree to... Wear loose comfortable clothing Wear trainers/sensible footwear suitable for exercising Stay hydrated by having a bottle of water/energy drink close by Let TriNeet Fitness know periodically how I feel about the training session (too hard, too easy, just right") Ask for a water break if I need it After the training session I will... Take part in stretching and cool down exercises Feedback any thoughts which can be taken into consideration for the following session
