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Blog
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Xtreme Fat Loss Programme
About
The Resilience Coaching Principles
Contact Me
Physical Activity Readiness Questionnaire – PARQ
Before you start training with me, you must complete this PAR-Q. The information contained within this form will help determine if it is safe for you to do so.
If there is ever any doubt regarding your fitness to train you should seek advice from your doctor.
If you or anyone in your household or immediate workplace are showing any of the symptoms of COVID-19 shown below or test positive for COVID-19, you should not attend any in-person sessions and notify me as soon as possible.
A new continuous cough
Fever/high temperature (37.8C or greater)
Loss of, or change in, sense of smell or taste (anosmia)
A new continuous cough is where you:
have a new cough that’s lasted for an hour
have had 3 or more episodes of coughing in 24 hours
are coughing more than usual
A high temperature is feeling hot to the touch on your chest or back (you don’t need to measure your temperature). You may feel warm, cold or shivery.
If you have any more serious symptoms, including pneumonia or difficulty breathing, you should consider contacting the hospital.
All information you record on this form will be treated with the utmost confidentiality, it will be stored in a secure place and made available to you at any time. You are not required to provide information on health conditions, however by signing this form you are declaring that there is no health-related reason why you should not, or cannot, exercise.
Contact details
Title
*
Mr
Miss
Mrs
Other - (Please specify below)
Prefer not to say
Preferred title:
Name
*
First
Last
Address
*
Street Address
City
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Date of Birth
*
Date Format: DD slash MM slash YYYY
Contact Telephone Number
*
Email
*
Emergency Contact Name
*
Emergency Contact Telephone Number
*
Additional comments about contact details (if applicable):
Health assessment
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 (either prescription or non-prescription)?
*
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 I should be aware of?
*
Yes
No
Please provide details
*
Changes in health
If you proceed with an exercise and nutrition programme and, during that period, your health changes, please consult your doctor and inform me as soon as possible, as you may need to change or even suspend your physical activity.
Exercise history
Have you exercised regularly for more than three months in the last two years?
*
Yes
No
How would you describe your current level of fitness, overall health and wellbeing?
By submitting this form, I confirm and agree to the following:
The details I have provided are correct and that I will consult my doctor immediately if anything changes that may affect my ability to exercise or related to my emergency contact details.
If I feel light-headed, faint, chest pain, leg cramps, fatigue, discomfort, pain or nausea whilst exercising, then I will immediately stop.
To only use equipment which is suitable to my abilities and competencies and will seek advice if I do not know how to correctly use or operate it.
If I or someone in my household is showing signs show signs of COVID-19, I will notify my coach immediately.
Are you human? If so, please enter the details from the image below.
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