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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 Break
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 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 Break
Occupational Questions
What 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 Break
Recreational Questions
Do 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 Break
Medical Questions
Have 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.
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Freeform Fitness

Tel: 512-787-1732
Email: mike@freeformfitnessonline.com

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