Health, Lifestyle & Fitness Questionnaire
Consultation Form for CORE CONCEPTS FITNESS

PAR-Q (Physical Activity Readiness Questionnaire)

Please answer with as much information as possible.
(All submissions will be held private & secure)

Name:
(Full Name)
Your answer
Age:
Your answer
Check which services of Core Concepts Fitness that interest you:
(check activities of interest)
Activity Level/Amount (hours per week)
How much time do you spend doing physically active tasks or exercises?
Check your CURRENT activities
Check your PAST activities
Describe any and all physical ailments or symptoms that you CURRENTLY sense.
Scan your body and tell me what needs attention.
Your answer
Has your doctor ever said that you have a heart condition OR high blood pressure?
Do you ever experience chest pain?
Please list all medications taken (prescription or non)
Your answer
Have you ever been told to restrict or modify your physical activity due injury or illness?
(if yes, please describe below)
Your answer
What are your main concerns with your physicality?
What would you like to address in regards to your body?
Your answer
List your goals
Your answer
How can I help you achieve your goals?
(be as detailed as you need to be to let me know what you want)
Your answer
Your answer
Phone #
Your answer
How would you like me to contact you?
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