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Strong Hold Fitness New Client Questionnaire

This questionnaire is designed to help us understand your current lifestyle, goals, and any specific needs or preferences you may have. Please take 10-15 minutes to complete this form prior to your initial consultation.  Your responses will greatly inform our conversation and enable us to personalize a training plan that supports your health and fitness journey.

General Information

What is your preferred method of contact?
Preferred Appointment Method
Video call (e.g., FaceTime, Zoom)
In Person (applies to local clients only)
Birthday
Month
Day
Year

Current Lifestyle

How would you describe your daily activity level?
Which of the following best describes your current routine for physical activity?: Physical activity includes any intentional movement that requires energy, such as workouts, sports, recreational activities, and activities like walking or cycling. If not
What aspects of these activities do you find appealing or motivating?: What aspects of these activities do you find appealing or motivating?
How would you describe your current eating habits?: If not listed, select "Other" and provide more detail in the space provided below.
On average, how many hours of sleep do you get per night?
Less than 5 hours
5-6 hours
7-8 hours
More than 8 hours
On a scale of 1-10, how would you rate your current stress levels?
1-2
3-4
5-6
7-8
9-10

Health and Fitness Goals

What are your main health and fitness goals?: Select all that apply. If not listed, select "Other" and provide more detail in the space provided below.
What challenges or barriers have you faced in pursuing your health and fitness goals?: Select all that apply. If not listed, select "Other" and provide more detail in the space provided below.

Personal Preferences

What Strong Hold Fitness services are you interested in?
If you are not attending in-person classes, what type of space will you be using for your workouts? Select all that apply. If not listed, select "Other" and provide more detail in the space provided below.
What types of equipment will you have available for your workouts? Select all that apply. If not listed, select "Other" and provide more detail in the space provided below.

Physical Activity Readiness Intake Form

General Information

Birthday
Month
Day
Year

Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor or health care practitioner before becoming more physically active. Please allow 3-10 minutes to complete this form. If you have any issues or questions, please email Lily Cole at lilyicole26@gmail.com.

This form is a re-creation of the Physical Activity Readiness Questionnaire for Everyone (PAR-Q+), originally developed by the PAR-Q+ Collaboration. Source: https://eparmedx.com/

General Medical Information

Has your doctor ever said that you have a heart condition OR high blood pressure?
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?
Yes
No
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).
Yes
No
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? If YES, please explain in the open text field following the question.
Yes
No
Are you currently taking prescribed medications for a chronic medical condition?
Yes
No
Do you currently have a bone, joint, OR soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? If your answered YES please explain in the open text field following the question.
Yes
No
Has your doctor ever said that you should only do medically supervised physical activity?
Yes
No
In summary, did you answer YES to one or more of the questions listed above?
Yes - Continue on to the next question
No - Please skip to the Participant Declaration

Follow-up Questions About Your Medical Conditions

Since you answered YES to one or more of the General Health questions, we ask that you complete a short series of questions to gain further information.

If your answer to the first question is NO, please skip all subsequent questions.

Do you have arthritis, osteoporosis, or back problems?
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Answer NO if you are not currently taking medications or other treatments.
Yes
No
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?
Yes
No
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?
Yes
No
Do you currently have cancer of any kind?
Yes
No
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?
Yes
No
Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?
Yes
No
Do you have a heart or cardiovascular condition? This includes coronary artery disease, heart failure, or diagnosed abnormality of heart rhythm.
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Answer NO if you are not currently taking medications or other treatments.
Yes
No
Do you have an irregular heart beat that requires medical management (such as atrial fibrillation, premature ventricular contraction)?
Yes
No
Do you have chronic heart failure?
Yes
No
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?
Yes
No
Do you currently have high blood pressure?
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Answer NO if you are not currently taking medications or other treatments.
Yes
No
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? Answer YES if you do not know your resting blood pressure
Yes
No
Do you have any metabolic conditions? This includes Type 1 Diabetes, Type 2 Diabetes, and Pre-Diabetes.
Yes
No
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?
Yes
No
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, or dizziness
Yes
No
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?
Yes
No
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?
Yes
No
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?
Yes
No
Do you have any mental health conditions or learning difficulties? This includes Alzheimer’s, dementia, depression, anxiety disorder, eating disorder, psychotic disorder, intellectual disability, and Down Syndrome.
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Answer NO if you are not currently taking medications or other treatments.
Yes
No
Do you have Down Syndrome AND back problems affecting nerves or muscles?
Yes
No
Do you have a respiratory disease? This includes chronic obstructive pulmonary disease (COPD), asthma, and pulmonary high blood pressure.
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Answer NO if you are not currently taking medications or other treatments.
Yes
No
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?
Yes
No
If asthmatic, do you currently have symptoms of chest tightness, wheezing, labored breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?
Yes
No
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?
Yes
No
Do you have a spinal cord injury? This includes tetraplegia and paraplegia.
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Answer NO if you are not currently taking medications or other treatments.
Yes
No
Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?
Yes
No
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?
Yes
No
Have you had a stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event.
Yes
No
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? Answer NO if you are not currently taking medications or other treatments.
Yes
No
Do you have any impairment in walking or mobility?
Yes
No
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?
Yes
No
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?
Yes
No
Do you have a medical condition that was not previously listed (such as epilepsy, neurological conditions, kidney problems)?
Yes
No
In summary, do you currently live with one or more medical conditions?
Yes - Go to Participant Declaration pt. 2
No - Got to Participant Declaration pt. 1

Participant Declaration

If you answered NO to all of the General Health questions, you are cleared for physical activity. If you answered YES to one or more of the follow-up questions, you should seek further guidance from a medical professional before becoming more physically active..


I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that Strong Hold Fitness may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

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