Form Step 1 of 2 50% Regular physical activity is fun and healthy, and getting involved in a fitness program is very safe for most people. Please fill out the PAR-Q and answer the questions below to determine whether you are physically fit to proceed with an ongoing fitness program and whether a doctor's approval is necessary. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly:Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth* Age*Please enter a value between 0 and 100.Phone*Gender*Email* Is there a gym in your building?*YESNOMedical ConditionsDo you have any of the following?Heart ConditionDiabetesAsthma - UncontrolledShortness of BreathArthritis - Bursitis RheumatismHerniaRecent SurgerySacroiliac ProblemAnginaHigh Blood PressueKnee ProblemsBack ProblemsOther:1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? 2. Do you feel pain in your chest when you do physical activity? 3. In the past month, have you had chest pain when you were not doing physical activity? 4. Do you lose your balance because of dizziness or do you ever lose consciousness? 5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? If you answered "Yes" to any of the questions above, please inform your trainer before scheduling exercise. You may be required to bring a doctor's note before proceeding.By electronically signing below, you are certifying that the above statements are true and correct.* First Middle Last History:Are you currently enrolled in a fitness program?* Yes No If Yes, what your current weekly schedule?What have you done in the past to promote your health & fitness?*How did you feel at the time?Describe your experience in athleticsGoals:What are your fitness goals?*(Ex: weight loss, muscle gain, improve athletic performance, general fitness, etc.)What areas of your body do you want to focus on and why?*How long have you been thinking about achieving these goals?*Why have you waited until now?*What's different this time?*When would you like to start seeing results and when are you expecting to meet your fitness goals?*What do you expect it will take for you to achieve your goals within your desired time frame? Personal Training ProfileHave you ever worked with a personal trainer?* Yes No If Yes, how was your experience and were you satisfied with your results?If NO, why not?How would you rate your eating habits & understanding of nutrition as it relates to your goals?* Excellent Good Fair Poor Why?Do you currently take any vitamins or supplements?* Yes No If so, what do you take and why?What days & times are you available to work out?How do you feel after a great workout? Why?CommentsThis field is for validation purposes and should be left unchanged.