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In Case of Emergency Contact: ____________________________ Relationship:___________
Address: ____________________________ Phone: _______
Physician: ____________________________ Specialty: _______
Address: _______ Phone: _______
Are you currently under a doctor’s care: Yes No
If yes, explain: ____________________________
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, were the results: Normal Abnormal
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If yes, please list medications and reasons for taking: ____________________________
Have you been recently hospitalized? Yes No
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Do you smoke? Yes No
Are you pregnant? Yes No
Do you drink alcohol more than three times/week? Yes No
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Are you moderately active on most days of the week? Yes No
Do you have:
High blood pressure? Yes No
High cholesterol? Yes No
Diabetes? Yes No
Have parents or siblings who, prior to age 55 had: Yes No
A heart attack? Yes No
A stroke? Yes No
High blood pressure? Yes No
High cholesterol? Yes No
Known heart disease? Yes No
Rheumatic heart disease? Yes No
A heart murmur? Yes No
Chest pain with exertion? Yes No
Irregular heart beat or palpitations? Yes No
Lightheadedness or do you faint? Yes No
Unusual shortness of breath? Yes No
Cramping pains in legs or feet? Yes No
Emphysema? Yes No
Other metabolic disorders (thyroid, kidney, etc.)? Yes No
Epilepsy? Yes No
Asthma? Yes No
Back pain: upper, middle, lower? Yes No
Other joint pain (explain on back of form)? Yes No
Muscle pain or an injury (explain on back of Form)? Yes No
To the best of my knowledge, the above information is true.
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Par Q Forms for Personal Trainers

  • 1. Par Q Form Name: __________________________________ Date: _______________________________ Telephone: ______________________________ Date of Birth:_______ Age: _________ Height: _____________ Weight:________ In Case of Emergency Contact: ____________________________ Relationship:___________ Address: ____________________________ Phone: _______ Physician: ____________________________ Specialty: _______ Address: _______ Phone: _______ Are you currently under a doctor’s care: Yes No If yes, explain: ____________________________ 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, were the results: Normal Abnormal Do you take any medications on a regular basis? Yes No If yes, please list medications and reasons for taking: ____________________________ Have you been recently hospitalized? Yes No If yes, explain: ____________________________ Do you smoke? Yes No Are you pregnant? Yes No Do you drink alcohol more than three times/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 High cholesterol? Yes No Diabetes? Yes No Have parents or siblings who, prior to age 55 had: Yes No A heart attack? Yes No A stroke? Yes No High blood pressure? Yes No
  • 2. High cholesterol? Yes No Known heart disease? Yes No Rheumatic heart disease? Yes No A heart murmur? Yes No Chest pain with exertion? Yes No Irregular heart beat or palpitations? Yes No Lightheadedness or do you faint? Yes No Unusual shortness of breath? Yes No Cramping pains in legs or feet? Yes No Emphysema? Yes No Other metabolic disorders (thyroid, kidney, etc.)? Yes No Epilepsy? Yes No Asthma? Yes No Back pain: upper, middle, lower? Yes No Other joint pain (explain on back of form)? Yes No Muscle pain or an injury (explain on back of Form)? Yes No To the best of my knowledge, the above information is true. Signature ____________________________ Date____________________________ Witness ____________________________
  • 3. CLICK HERE TO ACCESS MORE PERSONAL TRAINER FORMS