Physical Readiness Take a moment to tell us a little about your physical readiness. Answering these questions will help us create a program customized to your current fitness level and goals. Physical Readiness Name* First Last Email* Phone*Height* Weight in lbs.*Age*Physician's Name* Physician's Phone*Section BreakPHYSICAL 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 any 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 problem 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, you must obtain a waiver from your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. Section BreakOccupational QuestionsWhat is your current occupation?* Does your occupation require extended periods of sitting?* Yes No Does your occupation require extended periods of repetitive movements?* Yes No Please explain these repetitive movements.Does your occupation require you to wear shoes with a heel (dress shoes)?* Yes No Does your occupation cause you anxiety (mental stress)?* Yes No Section BreakRecreational QuestionsDo you partake in any recreational activities (golf, tennis, skiing, etc.)?* Yes No Please list these activities.Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.)* Yes No Please list your hobbies.Section BreakMedical QuestionsHave you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?* Yes No Please explain the pain or injuries.Have you ever had any surgeries?* Yes No Which surgeries?Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes?* Yes No Please explain.Are you currently taking any medication?* Yes No Please tell us about your medications.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.