Let’s work together. Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Physical activity readiness questionnaire Please fill out this form completely and accurately. This information is essential to helping your trainer develop a program that addresses your needs, goals and interests and is safe and effective. Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? * Yes No Do you frequently have pains in your chest when you perform physical activity? * Yes No Do you lose your balance due to dizziness or do you ever lose consciousness? * Yes No Do you have a bone joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program? * Yes No Are you pregnant now or have you given birth within the last 6 months? * Yes No Have you had a recent surgery? * Yes No If you have marked yes to any of the above please provide more detail: Do you have any chronic illness or physical limitations such as asthma or diabetes? * Yes No If yes please specify: Do you have any injuries or orthopaedic problems such as bursitis, bad knees, back, shoulder, wrist or neck issues? * Yes No If yes please specify: Do you take any medications either prescription or nonprescription on a regular basis? * Yes No If yes please specify: How many hours sleep do you get on average per night? Once you submit this form, you'll be redirected to a terms & conditions form to complete.
