Fit4U New Client Form

Please fill out this form as accurately and completely as possible to help us learn more about you in order to customize your training plan.

Name*
FirstLast
Date
Email*
Enter EmailConfirm Email
Phone*
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Height (in.)
Weight (lbs.)
Age
Physician's Name
FirstLast
Physician's Phone
Physical Activity Readiness Questionnaire (PAR-Q)
Has a 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, consult 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.
General & Medical Questionnaire
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
If yes, please explain.
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
Do you partake in any recreational activities (golf, tennis, skiing, etc.)?*
- Yes
- No
If yes, please explain.
Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)?*
- Yes
- No
If yes, please explain.
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?*
- Yes
- No
If yes, please explain.
Have you ever had any surgeries?*
- Yes
- No
If yes, please explain.
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
If yes, please explain.
Are you currently taking any medication?*
- Yes
- No
If yes, please list.
Additional Information
Please take a moment to tell us about any other questions or concerns you may have about working out.

Fit4U New Client Form

Physical Activity Readiness Questionnaire (PAR-Q)

General & Medical Questionnaire