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Home
Training
Class Schedule
About
Contact
New Client Form
***To be completed after scheduling your first session***
Name
*
First Name
Last Name
Preferred Prounouns
She/her
He/him
They/them
Other pronouns
Email
*
Birthdate
*
MM
DD
YYYY
Phone (mobile)
*
(###)
###
####
Emergency Contact Name
*
Emergency Contact Phone
*
(###)
###
####
Physical Activity Readiness Questionnaire (PAR-Q)
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
Do you feel pain in your chest when you perform physical activity?
*
Yes
No
In the past month, have you had chest pain when you were not performing physical activity?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have a bone or joint condition that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
*
Yes
No
Do you know of any other reason why you should not engage in physical activity?
*
Yes
No
If you have answered "yes" to one or more of the above questions, consult your physician before engaging in physical activity. Please expand on any "yes" answers.
About You - Health Information
What is your occupation / how do you spend your days?
*
Do you spend extended periods of time sitting or doing repetitive movements? Please explain.
Do you partake in any active recreational activities (golf, tennis, skiing, hiking, walking, gardening)?
Have you ever had any pain or injuries (ankle, hip, back, shoulder, knee, etc.)? If yes, please explain.
Have you ever had any surgeries? If yes, please explain.
Has a physician ever diagnosed you with a chronic disease, such as coronary artery disease, hypertension, high cholesterol, diabetes, or COPD? If yes, please explain.
Are you currently taking any medications? If yes, please list.
Have you ever been pregnant or given birth? If so, please provide dates of pregnancies and/or births.
Have you ever been assessed by a pelvic floor or women's health physical therapist? If so, please provide approximate dates and what you were being treated for.
About You- Training
Why are you here? What are your goals for training?
*
When do you want to accomplish your goals? Do you have a timeline?
*
How will you know that you have reached your goal(s)?
*
Are you exercising or moving now? What are you doing?
*
How much time weekly can you reasonably commit to exercise or movement?
*
What are your barriers to exercise or to reaching your goals? What do you foresee could be roadblocks?
*
What motivates you?
*
Do you like verbal encouragement? Do you like loud, pumping music? Do you like frequent check-ins? Do you like checking off boxes? Do you like gold stars? Do you like seeing results? Do you like not being in pain? Take your time on this one.
What type of movement do you enjoy (or have you enjoyed in the past)?
*
What equipment do you have access to--at home or the gym? Please list all.
Thank you!
