PARQ Form – HOLISTIC BODY MOVEMENT

Welcome to Our

Physical Activity Readiness Questionnaire

Before starting a new fitness or wellness program, it’s important for us to understand your current health, background, and goals. This short questionnaire will help us:

Learn about your medical history and lifestyle.
Identify any potential risks or limitations.
Personalize your fitness or wellness plan safely and effectively.

How It Works

Please complete all required fields marked with *.
The form should take 3–5 minutes to fill out.
All information you provide will remain confidential and used only for assessment purposes.

Important Note

This questionnaire is not a substitute for medical advice. If you have any health concerns, please consult with a qualified healthcare provider before engaging in physical activity.

Name

Date of Birth

Phone Number

Address

Emergency Contact Information

Name

Phone Number

Your Health Goals

What health goals would you like to achieve in the next 3 months?

What are your main reasons for starting your wellness journey? (Select all that apply)

How would you describe your general health and fitness?

Additional Information

If you are between the ages 15 and 69, the following questions will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor.

Please read each question carefully and answer honestly by clicking YES or NO.

1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes NO

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

Yes NO

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

Yes NO

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

Yes NO

5. Do you have a joint problem that could be made worse by a change in physical activity?

Yes NO

6. Is your doctor currently prescribing medication for your blood pressure or a heart condition?

Yes NO

7. Do you know of any other reason why you should not take part in physical activity?

Yes NO

If you answered yes to one more questions you should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.

By typing your first and last name below you are confirming that you have read, understood, and accurately completed this questionnaire. You are confirming that you are voluntarily engaging in an acceptable of exercise, and understand that your participation involves a risk of injury.

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Amy Fowler

Certified Comprehensive Balanced Body Pilates Instructor

Certified NASM Personal Trainer

Certified Holistic Weight Loss Coach

Welcome to Our

Physical Activity Readiness Questionnaire

How It Works

Important Note

Join Our Mailing List

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