Physical Activity Readiness Questionnaire

Step 1 of 9 – ___Basic Info___

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Coach Query String

Name(Required)

First Last

Email(Required)

PLEASE USE THE EXACT EMAIL YOU USED WHEN PURCHASING YOUR TRAINING PROGRAM

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Age(Required)

Gender(Required)

Height (In Inches)(Required)

Current Weight (lbs)(Required)

Primary Goal(Required)

What is Your Short-Term Fitness Goal? (30-90 Days)(Required)

What is Your Mid-Term Fitness Goal? (90-180 Days)(Required)

What is Your Long-Term Fitness Goal? (180 + Days)(Required)

Rate The Level Of Accountability You Prefer(Required)

1 – Very little Accountability Needed. (Just occasional check-ins and words of encouragement.)

2 – Moderate Level of Accountability is Needed (Don’t let me get away with skipping workouts or check-in calls.)

3 – High Level of Accountability Needed (Frequent messages, don’t allow skipped workouts and do not accept excuses!)

Please Select A Coach(Required)

Milly

Please Select A Coach(Required)

Milly

Tate

Please Select A Coach(Required)

Milly

Tate

Cameron

Please Select A Coach(Required)

Milly

Cameron

Please Select A Coach(Required)

Tate

Please Select A Coach(Required)

Tate

Cameron

Please Select A Coach(Required)

Cameron

Please Select A Coach(Required)

Sammy

Please Select A Coach(Required)

Cameron

Sammy

Please Select A Coach(Required)

Tate

Cameron

Sammy

Which Featured Coach Were You Assigned?(Required)

Milly

Tate

Cameron

Sammy

Please Select A Coach(Required)

Tate

Sammy

Please Select A Coach(Required)

Milly

Tate

Sammy

Please Select A Coach(Required)

Milly

Cameron

Sammy

Please Select A Coach(Required)

Milly

Sammy

Physical Readiness

Please Check All That Apply. If None, Click “Next” On The Bottom Left.

Has your doctor ever said that you have a heart condition and that you should limit activity?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Is your doctor currently prescribing drugs for your blood pressure or heart condition?

Medical Condition. Please Check All That Apply. If None, Click "Next" On The Bottom Left.

Heart Condition

Asthma-uncontrolled

Shortness of Breath

Arthritis Bursitis

Osteoarthritis

Rheumatism

Hernia

Recent Surgery

Sacroiliac Problems

Angina

High Blood Pressure

Knee Problems

Back Problems

What Are Your Current Medications?

Do You Have Any Injuries That Affect Exercise?

Describe your occupation and typical workday(Required)

How Many Hours Each Day Do You Sit?(Required)

Less Than 1 Hour

2 – 4 Hours

4 – 6 Hours

More Than 6 Hours

What Kind of Shoes Do You Wear Most Often?(Required)

Flat Shoes

Athletic Shoes

Mid-Heel Dress Shoes

High Heels / Heeled Boots

How Would You Rate The Stress Level Of Your Job?(Required)

1 – Not Stressful

2 – Moderatly Stressful

3 – Short Periods of High Stress

4 – Long Periods of High Stress

5 – Stress In a Constant Potential Life Threatening Environment

What, If Any, Are Your Hobbies?

Personal Fitness Goals(Required)

Appearance (Aesthetics)

Cardiovascular endurance

Flexibility

Health (General)

Muscular definition

Muscular size (Hypertrophy)

Muscular strength/power

Speed & Agility

Self-esteem or confidence

Sports specific training

Stress reduction

Fat loss (Weight loss)

Corrective exercise (Post-rehabilitation)

Other fitness goals or desires not indicated above

Athletics, Sports & Recreation

In this section, please share the sport or recreational activities in which you participate. If you are an advanced athlete and require or desire sports specific training or corrective exercise please explain your needs in the “Additional Details” section at the bottom of this page. If you are not necessarily an advanced athlete but would like to participate in one of the Sport’s below please indicate your desire in the “Additional Detail” section at the bottom of the page.

American Football

Baseball

Basketball

Ice Hockey

Soccer

Tennis

Golf

MMA or Wrestling

Marathon Athlete

Triathlon Athlete

Hiking – Back Country

Oar or Paddle Boating

Tough Mudder, Spartan or Other Hybrid Event

3,k, 5k or 10k Runs (Leisure or Competitive)

Any Other Sport or Activity Not Listed:

Additional Details – Please Specify Needs Related to Your Sport

Please describe your current activity or workouts(Required)

Rate your experience with exercise(Required)

Beginner

Intermediate

Advanced

Competitor

Rate your overall activity level(Required)

Sedentary

Moderately active

Active

Very Active

Competitor

Rate your ability to perform cardio exercises(Required)

Very low

Fair

Average

Good

Competitor

What form of cardio do you like best?(Required)

Running – Outside

Walking – Outside

Running – Treadmill

Walking – Treadmill

Elliptical Trainer

Stationary Bike

Recumbent Bike

Stair Climber

Other

How Would Your Rate The Quality of Your Nutrition?(Required)

Very Poor (Fast Food, Microwave Meals, Soda, or Sweets)

Poor (Some Fast Food, Occasional Microwave Meals, Soda, and sweets)

Average (Rarely eat Fast Food or Microwave Meals, Occasional Soda and Sweets)

Mildly Healthy (Almost No Fast Food or Microwave Meals. Rare Soda or Sweets)

Healthy (No Fast Food or Microwave Meals. No Sods and Rare Sweets)

How Many Alcoholic Beverages Do You Consume Weekly?(Required)

None

1-3

3-6

6 or more

What equipment do you have access to?(Required)

Free weights (dumbbell/barbells)

Gym machines (Freemotion, Precor, Cybex, etc.)

Cable machines

Resistance bands

Bosu ball

Stability ball

Kettlebells

Suspension training (TRX)

Bowflex or other home gym

No equipment

Please Check All That Apply

Please Describe Your Training Enviroment(Required)

Dietary Preferences(Required)

What Days Do You Plan To Work Out(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How Frequently Do You Expect To Exercise(Required)

1 – 3 days each week

4 – 5 days each week

6 – 7 days each week

I plan to follow my trainers recommendation

Is there anything else you would like your trainer to know?

Physical Activity Readiness Questionnaire

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