Preliminary Client Information

Daily Inspirational Quote:

Take care of your body. It's the only place you have to live.

Jim Rohn

Active Image
2482 Yonge Street
Ste. 45112
Toronto, Ontario
M4P 3E3
Tel: (416) 410-8517
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Preliminary Client Assessment

Name:	Required
Your email:	Required
Address:
Address 2:
City:
Province:
Postal Code:
Daytime Telephone:
Evening Telephone:

What is your age?
What is your height?
What is your current weight?
What is your desired weight?
If weight loss is your goal, indicate any specific areas of your body that you think need the most attention:
If muscle conditioning is your goal, indicate any specific areas of your body that you would like to concentrate on:
How much time are you willing to devote to exercise? Indicate the number of days per week and the amount of time per day.
What is the best time of day for you to exercise? Indicate early mornings, daytime, evenings, weekends.
Do you have any exercise equipment at home? Please specify.
What is your current exercise routine?
Is there anyone who is supportive of your goals?
How do you feel a personal trainer can best assist you?
Are you prepared to give up or cut down on certain types of foods?
What vitamins and supplements are you currently using?
Are you interested in learning more about the benefits of nutritional cleansing?
Please indicate all of the barriers that have kept you from reaching your fitness goals.
What behavious, beliefs or challenges do you have that could stand in the way of you achieving fitness goals?
In order for me to coach you effectively, what should I know about you? In other words, how do you think? How do you reach decisions? What motivates you?
How did you hear about Active Image?	did

PAR-Q

For most people physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.

Common sense is your best guide in answering these few questions. Please read them carefully and check the yes or no opposite the question if it applies to you.

yes	no
		1. Has your doctor ever said that you have a heart condition and recommended only medically approved physically activity?
		2. Do you have chest pain brought on by physical activity?
		3. Have you developed chest pain at rest in the past month?
		4. Do you lose consciousness or lose your balance as a result of dizziness?
		5. Do you have a bone or joint problem that could be aggravated by physical activity?
		6. Is your doctor currently prescribing medication for your blood pressure or heart condition? (e.g.: diuretics or water pills)
		7. Are you aware, through your own experience or a doctor's advice, of any other reason against your exercising without medical approval?

If you answered YES to one or more questions...

If you have not recently done so, consult with your personal physician by telephone or in person before increasing your physical activity and/or taking a fitness test.

If you answered NO to all questions...

If you answered PAR-Q accurately, you have reasonable assurance of your present suitability for an exercise test.

Notes:

1. This questionnaire applies only to those 15 to 69 years of age.

2. If you have a temporary illness, such as fever, or are not feeling well at this time, you may wish to postpone the proposed activity.

3. If you are pregnant, you are advised to consult with your physician before exercising.

4. If there are any changes in your status relative to the above questions, please bring this information to the immediate attention of your fitness professional.

Source: Derived from 'Physical Activity Readiness Questionnaire, British Columbia Ministry of Health Department of National Health and Welfare, Canada, revised 1992.

Please be sure *all areas are completed* before pressing 'Submit'. Incomplete forms will produce an error and entries will be lost. Hint: Answers can be typed in a word processing program or notepad first, then pasted into the form.

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The information contained within ActiveImage.ca is for educational purposes. It is here to help you made informed decisions about your fitness and health. It is not medical advice and is not intended to replace the advice or attention of health-care professionals. Please consult your doctor before beginning or making changes to your diet, exercise program, for diagnosis and treatment of illness and injuries, and for advice regarding medications and supplements.

In no way will Active Image or any persons associated with Active Image be held responsible for any injuries or problems that may occur due to the use of this website or the advice contained within. Active Image will not be held responsible for the conduct of any companies and websites recommended within this site.