Participant Background

participant informatiON

Please complete the form below and click the SUBMIT button to begin your journey. Thank you!

* Indicates required field

Name *

First

Last

Email *

Cell Phone *

Birthdate *

Select One *

Birth Year *

Age *

physical activity readiness questionnaire

PAR – Q & YOU Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions below. The PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one: CHOOSE YES or NO.

Informed Use of the PAR-Q: Progressive Fitness Coaching, LLC and their agents assume no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

YES NO

DELAY BECOMING MUCH MORE ACTIVE
If you are not feeling well because of a
temporary illness such as cold or a fever.
Waituntil you feel better; or If you are or
may be pregnant-talk to your doctor before

Do you feel pain in your chest when you do physical activity? *

YES NO

In the past month, have you had chest pain when you were not doing 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 drugs (for example, water pills) for your blood pressure or heart condition? *

YES NO

Do you know of any other reason why you should not do physical activity? *

YES NO

NO to all ALL...
If you answered NO honestly to all PAR-Q questions, you can
reasonably sure that you can: Start becoming much more physically active – begin slowly and
build up gradually. This is the safest and easiest way to go. Take part in a fitness appraisal – this is an excellent way to
determine your basic fitness so that you can plan the best way for you to live actively.

YES to one or more questions
Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a
fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity
you want – as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are
safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. Find out which community programs are safe and helpful for you.

CORONAVIRUS AND EXERCISE
Individuals at most risk for the severe effects of coronavirus have other medical complications or a compromised immune system.
Here are some simple recommendations to keep your immune system strong.
1.Get a good night’s sleep. Sleep deprivation causes an increase in cortisol levels independent of exercise.
2.Maintain hydration levels before during and after your workout. Dehydration increases the cortisol response
3.Pay attention to refueling especially during a longer workout. Consuming a carbohydrate/protein sports drink during your workout will minimize cortisol elevation and muscle protein breakdown.
4.Don't skip your recovery nutrition. Consuming a carbohydrate/protein recovery drink within 45 minutes post workout can pay dramatic dividends by reducing cortisol levels and minimize inflammation both factors which negatively impact your body's defense mechanisms.
5.Reduce the number of high volume, high intensity workouts per week.
6.Take a rest day after a particularly hard workout. This is a good practice even if there was not threat of coronavirus.
Last but not least, don’t stop exercising. In this time of heightened anxiety nothing relieves mental and physical stress better than exercise plus the added benefit of keeping your immune system strong!

INSTRUCTIONS
This is your comprehensive participant information sheet, in which you are asked to provide some relevant personal
information. The answers to these questions are essential in order to allow us to design an optimized individual
fitness program for you. Please answer all questions in the most accurate manner possible while being as concise
as possible.
DISCLAIMER
Please recognize the fact that it is your responsibility to work directly with your physician before, during, and after
seeking fitness consultation. As such, any information provided is not to be followed without the prior approval of
your physician. If you choose to use this information without the prior consent of your physician, you are agreeing to
accept full responsibility for your decision.

Do you knowingly accept this responsibility? *

NO I do not accept responsibility YES I do accept responsibility

Part 1: basic information

Height *

Weight (as of this morning) *

Resting Pulse *

Blood Pressure *

PART 2: GOALS

Given the following goals, please rank them in order of importance, with 1 being most important

Number 1 Goal *

2nd Most Important *

3rd Most Important *

4th Most Important *

*If you chose "Improved Health" in one of the drop-down menus above, please define what "Improved Health" means to you? *

If you chose "Sport Specific" from a drop-down menu, Please provide the sport or athletic event for which you are training: *

Do you have a specific timeline for achieving a specific goal? If so, please specify: *

Please select which type of progress is more important to you: *

Immediate progress that’s less easily maintained Maintainable progress that may not be as rapid

Please explain why selected this response? *

PART 3: EXERCISE INFORMATION

Please rate your ability in the following exercises (check the box that corresponds with your ability):

Are you currently exercising regularly (at least 3x per week)? *

If you answered YES above, continue on to the following section.
If you answered NO, skip ahead to the section marked “Not currently exercising”.

Complete this section if you ARE currently exercising regularly

How long have you been consistently exercising without a break? *

Please rank your most consistent to least consistent exercise routines/modalities

Most Consistent *

Next Most consistent *

Least Consistent *

How long is your typical workout? *

Complete this section if you ARE NOT currently exercising regularly

If you are not currently exercising regularly, have you ever been on a consistent exercise plan (at least 3x per week)? *

No Yes

If you have exercised on a consistent basis previously, how long ago was this and how long did it last? *

PART 4: MEDICAL AND HEALTH INFORMATION

If you have any diagnosed health problems, list the condition(s) *

What, if any, additional therapies or interventions are being undertaken for your given health issue(s)? *

If you currently taking any prescribed medications, please list them here *

Do you have any current injuries? If yes, please explain in further detail below. *

Are there any prior injuries that may affect your participation in this program? If yes, please explain in further detail below. *

Check any conditions or diseases you now have or have had in the past.

If you checked any of these, please explain here *

PART 5: LIFESTYLE INFORMATION

What do you do for a living? *

Does your job involve shift work? *

YES NO

Are you a primary caregiver for.. children, individuals with a disability, or an elder relative? *

How often do you travel? *

How many hours of uninterrupted sleep do you feel you average per night? *

Do have trouble falling asleep at night on a regular basis? *

Do you have trouble waking in the middle of the night and not being able to go back to sleep? *

Do you use any sleeping aids? *

Yes No

Please list the physical activities that you participate in outside of the gym and outside of work *

How much, on average, do you/your household spend on groceries per month (provide amounts from your last two grocery bills)? *

How often do you eat in restaurants and/or fast food places per week? *

How many times per week do you/your household shop for groceries? *

How much do you spend on vitamins/supplements per month? *

If you have any known food allergies, please list them below. *

Are there any other foods to which you’re particularly sensitive (i.e., which cause excessive gas, bloating, stuffiness, or congestion)? *

If you’re currently using any nutritional supplements, please list them (as well as the doses you’re taking) below *

Would you be willing to complete a three-day dietary/nutrition record so that we further assist you with your fitness/nutrition goals? *

YES I'd like that NO I'm not interested at this time

Is any other information you think might be relevant to your program design, please share it with us below. *

Please share your most frequent health, nutrition, or physique complaints and/or dissatisfactions. *

Informed Consent:
Exercise has a great many benefits along with certain risks. I hereby expressly assume all delineated risks of injury, all other possible risks of injury, and even death, which could occur by reason of my participation in increased physical activity.

I agree to the Informed Consent above *

Please Enter Your Full Name *

I agree to receiving marketing and promotional materials

Submit

participant informatiON

physical activity readiness questionnaire

Part 1: basic information

PART 2: GOALS

PART 3: EXERCISE INFORMATION

PART 4: MEDICAL AND HEALTH INFORMATION

PART 5: LIFESTYLE INFORMATION

© 2022 Progressive Fitness Coaching, LLC. All Rights Reserved. PO Box 1076 Hockessin, DE 19707 (302) 521-1794