Physical Activity Readiness Questionnaire
Email address *
Date *
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Participant (last name) *
Your answer
Participant (first name) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Phone Number (Participant) *
Your answer
Email Address (Participant) *
Your answer
Parent/Guardian (last name) *
Your answer
Parent/Guardian (first name) *
Your answer
Phone Number (Parent/Guardian) *
Your answer
Email Address (Parent/Guardian) *
Your answer
Address *
Your answer
Fitness Goals (check all that apply) *
Required
Medical History
Do you have a heart condition that you are aware? *
Are there any limitations to your heart condition? *
Do you have any other major illness that we should be made aware of? *
Please explain illness
Your answer
Do you smoke? *
Do you drink alcohol *
Are you on any current medications?
Please list any type of medications you are currently taking?
Your answer
Please list any type of supplements and or vitamins that you are currently taking?
Your answer
Exercise History
Frequency of weekly exercise
Nutritional Habits *
Required
Initials (Parent/Guardian if Participant is under 18) *
Your answer
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