Client intake questionnaire (PAR-Q style)
Trainer: Trainer or business name
Client name: ______________________ Date of birth: ______________
Contact (email / phone): ______________________
1. Health screening
(circle or tick your answer)
Has a doctor ever told you that you have heart disease or high blood pressure?☐ Yes ☐ No
Do you feel chest pain during physical activity?☐ Yes ☐ No
In the past month, have you felt chest pain while at rest?☐ Yes ☐ No
Do you lose your balance because of dizziness, or have you lost consciousness in the past year?☐ Yes ☐ No
Do you have a joint, bone, or back problem that exercise could make worse?☐ Yes ☐ No
Do you take medicine for blood pressure, your heart, or another long-term condition?☐ Yes ☐ No
Have you had surgery or a serious injury in the past year?☐ Yes ☐ No
Is there any other reason why you should not increase your level of physical activity?☐ Yes ☐ No
If you answered YES to any question, please add details below and consult a doctor before starting more intensive training:
________________________________________________________________
________________________________________________________________
2. Client declaration
I confirm that I have answered the questions above truthfully and completely. I agree to inform the trainer if my health changes.
Place: ___________ Date: ___________
Client signature: ______________________
Template questionnaire generated with a Socra.fit tool. This template does not replace a medical examination or professional consultation.