New Form

PAR-Q (Physical Activity Readiness Questionnaire)

AGREEMENT FOR SERVICES FROM DESTINY MANAGEMENT

• This agreement is made on*
  
  Date Format: MM slash DD slash YYYY
  
• For most people, physical activity should not pose any problem or hazard. This questionnaire has been designed to
  identify those people for whom physical activity might be inappropriate, or those who should have medical advice
  concerning the type of activity most suitable for them. If you answer “yes” to any of the questions below, consult
  with your doctor before starting any exercise program.
• Name*
• Last Name*
• Gender
  • Male
  • Female
• Address*
  
  Street Address
  
  Address Line 2
  
  City
  AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
  State
  
  ZIP Code
  
• Home Phone
• Business Phone
• Email
  
• Birthdate
  
  Date Format: MM slash DD slash YYYY
  
• Age
• Employers Name
• Height – ft/in
• Weight (lbs)
• Date of Last Physical Exam
  
  Date Format: MM slash DD slash YYYY
  
• Personal Physician
• Phone
• Goals
• Limitations
• How many days per week can you commit to a resistance program?
• How may days per week can you commit to a cardiovascular program?
• What is the total amount of time per day you can commit to an exercise program?(in minutes)
• How can we best assist you with a nutrition program?
• How did you hear of Destiny Management

• General History

• Do you currently have an illness or infection?
  • Yes
  • No
• Please Specify: