247 Fitness Personal Training & Coaching Application

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Date of Birth *

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What is your preferred method of contact *

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PAR-Q - Physical Activity Readiness & Health Questionnaire

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 chest pain when you do physical activity? *

Yes
No

In the past month have you had chest pain when you are NOT doing physical activity? *

Yes
No

Are you pregnant or have you recently given birth and not yet been cleared for exercise? *

Yes
No

Has a physician ever advised you not to participate in physical activity or to exercise only under medical supervision? *

Yes
No

Do you CURRENTLY have any injury, illness, pain, dizziness, chest pain, or other medical condition that could make exercise unsafe? *

Yes
No

If you answered YES to any of the above questions, please provide an explanation below:

Have you ever had a serious injury to a bone, joint, muscle, tendon, or ligament that could affect your ability to exercise? *

If Yes, please describe the injury, the approximate date (if known), whether it was the RIGHT, LEFT, or BOTH sides, and whether you still experience any pain, stiffness, weakness, or limitations. If not, answer No.

Do you currently have, or have you previously been diagnosed with, any of the following health conditions? *Please select all that apply. *

Please provide any details about your health that may be relevant to your training, including how the condition is currently being managed.

This question is optional.

Are you currently taking any prescription or non-prescription medications regularly, including aspirin, Tylenol, Advil or hormonal birth control? If yes, please list the medication(s) and why you take them.

This question is optional

Lifestyle Questions

What is your current occupation(s)? *

Are you a parent? *

Yes
No

How old are your children? *

exercise/training and are

Which option best describes your current overall activity level, including exercise, work and daily movement? *

Mostly sedentary: I spend most of the day sitting and do little regular exercise.
Lightly active: I do some regular walking, daily movement or light exercise 1–2 days per week.
Moderately active: I move regularly and exercise approximately 3–4 days per week.
Very active: I exercise most days, have a physically active job or regularly participate in demanding activities.
Not sure

Which best describes your current exercise/training experience? *

I'm new to exercise.
I have some exercise experience.
I'm returning to exercise after a break.
I currently exercise somewhat regularly.
I'm currently very active and exercise regularly.
Other

What sports, activities or hobbies do you currently do regularly? *

Is there anything you can't do now, that you want to be able to do in the future? *

Goals & Motivation

What would you most like help with? *Please select all that apply. *

What are your 3 most important health and fitness goals and why is each one important? *

What has made it difficult to reach or maintain your goals in the past? *

Training & Coaching Logistics

How often would you like to train with me? *

What days and times would you be available to train? *

Are you currently a member or 247 Fitness Amherstview? *

Yes
No, but I am willing to obtain a membership

How much support are you interested in receiving? *

Personal training only
Personal training with some nutrition and lifestyle guidance
Personal training with ongoing nutrition and lifestyle coaching
I’m not sure yet

Is there anything else you would like me to know before we meet? *

Liability Waiver & Informed Consent

I understand that my complimentary consultation may include a few simple movement assessments and that any physical activity carries potential risk of discomfort or injury.

I confirm that the health information I provided is accurate. I voluntarily agree to participate and accept the associated risks. To the fullest extent permitted by law, I release Tanya S. Masse and 247 Fitness Amherstview from liability arising from my participation. I understand that I may decline or stop any assessment at any time.

Full Name *ELECTRONIC SIGNATURE *

Today's Date *

Consent *

I have read, understand, and agree to the Liability Waiver & Informed Consent above. I understand that by checking this box, typing my full legal name, and submitting this form, I am providing my electronic signature.

Captcha Question *

What is 7+4?