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Resilience Fitness

Resist – Persist – Overcome

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Physical Activity Readiness Questionnaire – PARQ

Name*
First Last
Address*
Street Address City ZIP / Postal Code Country
Date of Birth*
Date Format: DD slash MM slash YYYY
Contact Telephone Number*
Email*
Emergency Contact Name*
Emergency Contact Telephone Number*
Have you ever had any medical condition, surgical operation or injury?*
- Yes
- No
Please provide details*
Do you suffer chest pains upon exertion and/or at rest?*
- Yes
- No
Please provide details*
Do you regularly take medication?*
- Yes
- No
Please provide its name, dose and for what it is prescribed*
Do you suffer from regular headaches, dizziness, fainting or fits?*
- Yes
- No
Please provide details*
Is there a possibility that you have been pregnant, or have you given birth in the last 6 months? (Also note any miscarriage, pregnancy or fertility problems)?*
- Yes
- No
Please provide details*
Do you have high blood pressure?*
- Yes
- No
Are you over the age of 65 and unaccustomed to vigorous exercise?*
- Yes
- No
Do you have any bone or joint problems that could be affected by exercise?*
- Yes
- No
Please provide details*
Do you have any food allergies, intolerances or sensitivities?*
- Yes
- No
Please provide details*
Is your GP aware of your intention to modify your exercise and nutrition behaviours?*
- Yes
- No
Is there any further information you feel we should be aware of?*
- Yes
- No
Please provide details*
Are you human? If so, please enter the details from the image below.

About The Company

Resilience Fitness was founded to help people achieve optimal well-being through individualized exercise and nutrition. The service is bespoke and personal, with no two people coached the same way. My goal is to build a better future for my clients and the people most important to them.

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Contact Me

If you're interested in working with me, want more information on my services or simply have a question that you think I might be able to answer, then get in touch using the form below. I'd love to hear from you.
Name*
Email*
Message
Are you a real person? Please enter the details shown below.

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