Program Design Questionnaire Form

Name*

Email*

please enter the email which you used before purchasing our program.

Phone*

Address*

Date of birth*

Gender*

What is your height in cm?*

What is your current weight in kg?*

Goal*

My physical activity level is currently...*

How many days per week do you currently workout (or exercise with sports)?*

In terms of my Exercise Knowledge, I am a...*

I currently have access to the following equipment (either at home or the gym)*

What are your most important fitness goals?*

On a scale of 1-10, how committed do you feel you are to making this change?*

Do you have any medical conditions that could affect your program that we should be aware of? (i.e. Diabetes, High Blood Pressure, Injuries, Any other conditions)*

If so, please explain

Has your doctor or GP cleared you for exercise?*

Yes
No

How many meals do you typically eat each day?*

How many meals could you realistically eat each day?*

Dietary Requirements/Restrictions*

Please Specify

What would be your ideal breakfast, lunch and dinner?*

Please list what you would love to have as part of your plan. (Make it realistic to your goals - having a McDonalds breakfast might be your fav, but it's probably not going to serve your goals 🤣).

When do you want to start?*

Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor?*

Yes
No

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

Yes
No

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

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness?*

Yes
No

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?*

Yes
No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*

Yes
No

Do you know of ANY OTHER REASON why you should not do physical activity?*

Yes
No

If you answered 'YES' to one or more questions,

Talk to your doctor by phone or in-person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.

You may be able to do any activity you want – as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

Find out which community programs are safe and helpful for you.

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can: Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go. Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively.

Delay becoming much more active: If you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better If you are or may be pregnant – talk to your doctor before you start becoming more active.

Please note:

If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

Program Design Questionnaire

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