Personal Training Form - Urban Health & Fitness

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Personal Training PAR-Q Form

Fill out this form to the best of your ability. We will then review your information and pair you with a trainer.

"*" indicates required fields

Name*

First Last

Email*

Phone*

Date of Birth*

MM slash DD slash YYYY

Age*

Height*

Weight*

In Case of Emergency Contact

Name*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Health Care Information

Are you currently under the care of a doctor?*

Yes

No

If yes, please explain:

Doctor's Name

Specialty

Doctor's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

When was the last time you had a physical examination?*

Have you ever had an exercise stress test?*

Yes

No

Don't know

If yes, we're the results:*

Normal

Abnormal

Do you take any medications on a regular basis?*

Yes

No

Please list medications and reasons for taking:*

Have you been hospitalized recently?*

Yes

No

If yes, please explain:*

Do you smoke?*

Yes

No

Are you pregnant?*

Yes

No

Do you drink alcohol more than 3 times per week?*

Yes

No

Is your stress level high?*

Yes

No

Are you moderately active on most days of the week?*

Yes

No

Do you have high blood pressure?*

Yes

No

Do you have high cholesterol?*

Yes

No

Do you have diabetes?*

Yes

No

Do you have parents or siblings who, prior to age 55 had a heart attack?*

Yes

No

Do you have parents or siblings who, prior to age 55 had a heart stroke?*

Yes

No

Do you have parents or siblings who, prior to age 55 had high blood pressure?*

Yes

No

Do you have parents or siblings who, prior to age 55 had high cholesterol?*

Yes

No

Do you have parents or siblings who, prior to age 55 had heart disease?*

Yes

No

Do you have parents or siblings who, prior to age 55 had rheumatic heart disease?*

Yes

No

Do you have parents or siblings who, prior to age 55 had a heart murmur?*

Yes

No

Do you experience chest pain with exertion?*

Yes

No

Do you have an irregular heart beat or palpitations?*

Yes

No

Do you experience light headedness or do you faint?*

Yes

No

Do you experience unusual shortness of breath?*

Yes

No

Do you experience cramping pains in legs or feet?*

Yes

No

Do you have emphysema?*

Yes

No

Do you have any other metabolic disorders (thyroid, kidney, etc)?*

Yes

No

Please describe your metabolic disorder:

Do you have epilepsy?*

Yes

No

Do you have asthma?*

Yes

No

Do you experience back pain?*

Yes

No

Where is your back pain?

Upper back

Mid back

Lower back

Do you experience joint pain?*

Yes

No

Where is your joint pain? How severe is it?*

Do you experience muscle pain or are you suffering from an injury?*

Yes

No

Please explain:*

Digital Signature*

By checking this box I am affirming that, to the best of my knowledge, the above information is true.

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409-621-2878
support@galvestongyms.com
2009 Post Office St, Galveston TX 77550

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