Physical Activity Readiness Questionnaire

Your Name (required)

Your Email (required)

Your Phone (required)

Date of Birth

Height in cm

Weight in kg

Sex
MaleFemaleOther




Major risk factor identification


1. Do you have diabetes?
YesNoDon't know

2. Are you clinically obese?
YesNoDon't know

3. Is your TOTAL cholesterol to HDL cholesterol ratio greater than 5 to 1
YesNoDon't know

4. Have you ever had an abnormal exercise ECG?
YesNoDon't know

5. Do you have a history of high blood pressure?
YesNoDon't know

6. Do you have a family history of coronary or other atherosclerotic disease prior to age 50?
YesNoDon't know




PERSONAL MEDICAL HISTORY


Have you ever suffered:

1. Heart attack
YesNoDon't know

2. Had bypass surgery
YesNoDon't know

3. Cardiac surgery
YesNoDon't know

4. Extreme chest discomfort
YesNoDon't know

5. High blood pressure over 145/95
YesNoDon't know

6. Over 35 and smoke
YesNoDon't know

7. Serum cholesterol over 240mg/dcl
YesNoDon't know

8. Irregular heart beat
YesNoDon't know

9. Heart murmurs
YesNoDon't know

10. Rheumatic fever
YesNoDon't know

11. Ankle swelling
YesNoDon't know

12. Any vascular disease
YesNoDon't know

13. Phlebitis
YesNoDon't know

14. Unusual shortness of breath
YesNoDon't know

15. Fainting
YesNoDon't know

16. Asthma, emphysema, or bronchitis
YesNoDon't know

17. Abnormal blood fat levels
YesNoDon't know

18. Stroke
YesNoDon't know

19. Emotional disorders
YesNoDon't know

20. Recent illness, or hospitalisation
YesNoDon't know

21. Drug allergies
YesNoDon't know

22. Orthopaedic problems, or arthritis
YesNoDon't know

Do you currently have any illness, injury or limitations?

YesNo

If yes, please give details:


Are you currently on any medication?
YesNo

If yes, please give details:




GENERAL INFORMATION


On average, how many hours of QUALITY sleep to you get a night?

On average, how many litres of water/liquid do you consume in a day?

What is your current occupation?

How would you rate your current stress levels?




GOAL SETTING

If possible, list 3 goals for each section

Short term goals / 8-12 weeks

Medium term goals / 6-9 months

Long term goals / 12+ months




Exercise history

Are you currently following an exercise plan of any kind?
YesNo

If yes, please give details:

When was the last time you have exercised on a regular basis?

Please list your least favourite exercises:

Please list your favourite exercises:




Eating habits

Please list the foods and drinks you consume on a TYPICAL day. Please provide times and answer honestly.


Breakfast:

Snack:

Lunch:

Snack:

Dinner:

Snack:

Please list the foods and drinks you consume on a BAD day. Please provide times and answer honestly.

Breakfast:

Snack:

Lunch:

Snack:

Dinner:

Snack:




CONFIRMATION AND CONSENT

I confirm that I have answered all questions honestly, truthfully and to the best of my knowledge.

YesNo

I hereby give consent to ‘Stephan Konrad’ to perform additional screening assessments which may include the pinching of skin with a body fat calliper, measuring the circumference of various body parts with a tape measure and appropriate touching for postural and exercise form correction.

YesNo