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Physical Activity Readiness Questionnaire
Physical Activity Readiness Questionnaire
Name
*
Address: (home)
City: (home)
State: (home)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip-Code: (home)
Phone: (home)
Phone: (mobile)
Email:
Occupation:
Address: (work)
Phone: (work)
Phone II: (work)
DOB:
Age:
Sex:
Height:
Weight:
Desired Weight:
Does your occupation require you to perform any physically demanding activity?
Exercise
Which exercise goals and/or results are most important to you? Check all that apply:
Fat Loss
Improved Body Shape
Increased Muscular Endurance/Energy
Increased Bone Strength/Density
Physical Rehabilitation
Relief from Lower Back Pain
Increased Muscular Size & Strength
Cardiovascular Conditioning & Health
Improved Athletic Performance
Improved Flexibility
Relief from Stress / Muscular Tension
Relief from Neck Pain
Rate your commitment level to achieving these goals.
1
2
3
4
5
6
7
8
9
10
Number of months expected to attain goal:
What would you like to see change on your body in one month?
What would you like to look like 1 year from now?
What exercise and/or recreational activities have you participated in during the past, are currently engaged in, or plan to engage in the future?
How many days are you committed to workout each week?
1
2
3
4
5
6
7
How would you rate your exercise level:
Sedentary => Little or no recent history
Beginner => New exercise within past 6 months
Intermediate => Exercising regularly for the past year
Advanced => Well conditioned individuals
Professional => Amateur or professional athletes
How would you classify your current activity level?
Inactive
Light activity (i.e. a little walking)
Moderate activity (i.e. walking, light jogging, “taking the stairs”)
Demanding activity (i.e. running, aerobics)
Very demanding activity (i.e. strength training, mountain climbing)
Extended activity (i.e. triathlon or marathon running)
How much time per week do you exercise currently?
15-30 minutes
30-60 minutes
1-2 hours
2-4 hours
4 hours or longer
Have you ever worked out with a personal trainer?
Yes
No
If yes, were you pleased with the results and level of service? Please explain.
Rate your level of Daily Stress:
1
2
3
4
5
6
7
8
9
10
Diet
How much water do you think you should drink per day?
1-6 glasses
6-10 glasses
10-16 glasses
1-2 gallons
2 gallons +
How much water do you drink per day?
1-6 glasses
6-10 glasses
10-16 glasses
1-2 gallons
2 gallons +
Do you use a water filter at home and work? If so what type/brand?
Do you drink alcohol?
Yes
No
If so, how much?
What other beverages do you drink?
List any food allergies:
List any foods that you refuse to eat:
Are you taking any supplements?
Yes
No
If so, which ones?
How often do you eat home cooked meals?
Never
Rarely
Sometimes
Often
Always
Do you have someone prepare meals for you?
Yes
No
How often do you eat in restaurants?
Never
Rarely
Sometimes
Often
Always
Have you ever worked with a nutritionist?
Yes
No
If yes, were you pleased with the results and level of service? Please explain.
Have you ever been on a weight loss program before?
Yes
No
If yes, which one(s)?
What type of eating pattern have you been told you should follow?
When was your diet the most disciplined?
What type of eating pattern did you follow at that time?
What and when did you eat yesterday?
Do you smoke?
Yes
No
If so, how much?
Have you ever done a detoxification diet/cleanse?
Yes
No
If yes which one (s)?
Medical History
List any and all health conditions, medical problems and medications:
List non-prescription drug use: (i.e. Aspirin).
List any recent injuries and/or medical procedures:
Select yes or no to the conditions listed below. If you answer yes to any, it may be necessary to obtain medical clearance before engaging in our exercise program.
Heart attack, coronary bypass or surgery
Yes
No
High blood pressure
Yes
No
Chest discomfort or pain during exertion
Yes
No
Low blood pressure
Yes
No
Frequent Headaches
Yes
No
Heart beat irregularities
Yes
No
Muscular skeletal diseases (i.e. MS, MD, AMS, or Cerebral Palsy)
Yes
No
Vascular disease
Yes
No
Phlebitis, emboli
Yes
No
Shortness of breath, especially during mild exertion
Yes
No
Light headedness or fainting spells
Yes
No
Cardiorespiratory disease (i.e. asthma, bronchitis)
Yes
No
High or Low cholesterol or triglyceride levels
Yes
No
Stroke
Yes
No
Past orthopedic injuries
Yes
No
Recent illness (serious), hospitalization or surgery within past 6 months
Yes
No
If yes, to what degree has the injury been rehabilitated?
Diabetes or other metabolic disorders
Yes
No
Gout
Yes
No
Current pregnancy
Yes
No
Is there a history of cancer in your family?
Yes
No
Is there a history of cancer in your family?
Has your doctor ever told you that you have a bone, joint or any other orthopedic problem that has been or could be made worse by resistance training?
Yes
No
Would your physician object to your dieting or exercising?
Yes
No
Would your physician object to your dieting or exercising?
Yes
No
Is there any reason not mentioned on the previous page why you should not follow a regular resistance-training program? If so what is the reason?
For any of the conditions checked above, please list the diagnosis and examining physician.
Examining Physician:
Phone number:
When was your last comprehensive physical examination?
Primary Physician:
Phone Number
Symptoms
Do you have any of the following symptoms? Check all that apply.
Fibromyalgia
Chronic Fatigue
Chronic Headaches
Migraine Headaches
Brain Fog/Poor Concentration
Anxiety
Cold Hands & Feet
Night Sweats
Depression
Dark Circles under the Eyes
Candida
Metallic Taste in Mouth
Digestive Problems
Inability to Gain or Lose Weight
Chemical Sensitivities
Rashes
Allergies
Tremors
Frequent Colds or Flu
Joint Pain
Mood Swings
Cellulite
Acne
Burning Skin
Poor Dexterity
Memory Loss
Muscle & Joint Pain
General Malaise/Feeling Sick All Over
If you have ANY of the above symptoms, you may have chemical or heavy metal toxicity. Many of these symptoms can turn into more serious conditions if toxicity is left untreated
Sleep
Average sleep time in hours (weekdays)
Average sleep time in hours (weekends)
Do you sleep restfully?
Never
Rarely
Sometimes
Usually
Always
Do you find it difficult falling asleep or waking up in the morning?
Yes
No
Bowel Health
How often do you have a bowel movement?
1-2 / week
3-5 / week
1 / day
1-2 / day
3 or more / day
How often do you have diarrhea and/or constipation?
Daily
Bi-Weekly
Weekly
Monthly
Yearly
Never
How often do you experience gas and/or bloating?
Daily
Bi-Weekly
Weekly
Monthly
Yearly
Never
Holistic Care
Do you currently see a chiropractor?
Yes
No
If yes, are you pleased with the results and level of service? Please explain.
Do you currently see an acupuncturist?
Yes
No
If yes, are you pleased with the results and level of service? Please explain.
How often do you get a massage?
Daily
Bi-Weekly
Weekly
Monthly
Yearly
Never
Have you ever used a Far-Infrared Sauna?
Yes
No
If yes, please explain.
Have you ever seen a Colonic Therapist?
Yes
No
If yes, please explain.
Have you used other Holistic Modalities?
Yes
No
If yes, please explain.
Date
Name
