DPHA Solutions PAR-Q

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First and Last Name *

Email address *

Phone Number

Gender

What is your main focus? *

Fitness

Nutrition

Habit Forming

All of the above

Required

What are your fitness goals? (Weight loss, muscle gain, improved endurance, general health, other)

Why do you want to achieve these goals? *

Has a doctor advised you to avoid physical activity in the past six months? *

Yes

Do you have any medical conditions or injuries? (Please specify) *

Have you experienced fainting or lightheadedness during physical activity in the past six months? *

Yes

Maybe

Do you have any metabolic conditions that would affect your ability to workout? (i.e. diabetes, high blood pressure, heart conditions, etc...) *

What is your current fitness level? *

Sedentary (Inactive)

Lightly Active (1-2 days a week)

Moderatly Active (3-4 days)

Very Active (5 or more days)

Required

How would you describe your eating habits? *

Are you allergic to any foods? *

Which do you prefer? *

Chicken

Beef

Fish

Vegetables

Required

Have you ever worked with a personal trainer before? *

Yes

If yes, what were your likes sand dislikes?

Is there anything else you'd like to share that may help us understand your needs?

Submit

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