CLIENT INFORMATION

QUESTIONNAIRE

Please complete and return to us at least 2 days prior to your first

scheduled session.

All information received on this form will be treated as strictly confidential. Please
fill out the forms completely and accurately. This information is essential to
helping your trainer develop a program that addresses your needs, goals and
interests, and is safe and effective.

Name:_____________________________ Date of Birth____/____/____ Age:______

M D Y
Address:______________________________________________________________
Street City State Zip Code
Phone: __________________(h) __________________(o) _________________(c)

Email address: _______________________________________________________

Occupation:_____________________________________

Emergency Contact: _______________________ Relationship: ________________

Phone Number:________________________

Physician’s Name:_______________________ Physician’s Phone:_______________

Physician’s Address:____________________________________________________
Street City State Zip Code

Progress Fitness will send information regarding your physical exercise program to your physician
unless you request otherwise.

Please provide 24 hours notice if you need to cancel or reschedule your

Personal Training appointment.

Performance Training with

Coach Abdullah
Jeddah, Saudi Arabia
966 540206920
coach.abdullah.alkidd@gmail.com
www.coachabdullah.com

© Coach Abdullah Al-Kidd & Associates, LLC.

PAR-Q FORM Please mark YES or No to the following: YES NO

Has your doctor ever said that you have a heart condition and recommended
only medically supervised physical activity? ____ ____
Do you frequently have pains in your chest when you perform physical activity? ____ ____
Have you had chest pain when you were not doing physical activity? ____ ____
Do you lose your balance due to dizziness or do you ever lose consciousness? ____ ____
Do you have a bone, joint or any other health problem that causes you pain or
limitations that must be addressed when developing an exercise program
(i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis,
anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? ____ ____
Are you pregnant now or have given birth within the last 6 months? ____ ____
Have you had a recent surgery? ____ ____
If you have marked YES to any of the above, please elaborate below:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Do you take any medications, either prescription or non-prescription, on a regular basis? Yes/No
What is the medication for?_______________________________________________________
How does this medication affect your ability to exercise or achieve your fitness goals?
______________________________________________________________________________
____________________________________________________________________________

Lifestyle Related Questions:

1) Do you smoke? YES NO If yes, how many?__________

2) Do you drink alcohol? YES NO If yes, how many glasses per week?__________

3) How many hours do you regularly sleep at night? ___________

4) Describe your job:  Sedentary  Active  Physically Demanding

5) Does your job require travel? YES NO

6) On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)? ______

7) List your 3 biggest sources of stress:

a. _______________________ b. _______________________ c._______________________

8) Is anyone in your family overweight? Mother Father Sibling Grandparent

9) Were you overweight as a child? YES NO If yes, at what age(s)?______________

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Fitness History:
1) When were you in the best shape of your life? _____________________________________

2) Have you been exercising consistently for the past 3 months? YES NO

3) When did you first start thinking about getting in shape? _____________________________

4) What if anything stopped you in the past? _________________________________________

5) On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?_____

Nutrition Related Questions

1) On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)? _______

2) How many times a day do you usually eat (including snacks)? _______________

3) Do you skip meals? YES NO 4) Do you eat breakfast? YES NO

5) Do you eat late at night?  Sometimes  Often  Never

6) What activities do you engage in while eating? (TV, reading etc) ______________________

7) How many glasses of water do you consume daily? _____________

8) Do you feel drops in your energy levels throughout the day? YES NO If yes, when?______

9) Do you know how many calories you eat per day? YES NO If yes, how many?_____

10) Are you currently or have you ever taken a multivitamin or any other food supplements? Y N
If yes, please list the supplements:
___________________________________________________________________________
_________________________________________________________________________

11) At work or school, do you usually:  Eat out  Bring food

12) How many times per week do you eat out? _____________

13) Do you do your own grocery shopping? YES NO

14) Do you do your own cooking? YES NO

15) Besides hunger, what other reason(s) do you eat?

Boredom  Social  Stressed  Tired  Depressed  Happy  Nervous

16) Do you eat past the point of fullness?  Often  Sometimes  Never

17) Do you eat foods high in fat and sugar?  Often  Sometimes  Never

18) List 3 areas of your Nutrition you would like to improve:

a.________________________ b.________________________ c.________________________

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Exercise Related Questions: Skip to next section if you are presently inactive.
1) How often do you take part in physical exercise?
5-7x/week 3-4x/week 1-2x/week
2) If your participation is lower than you would like it to be, what are the reasons?

Lack of Interest Illness/Injury Lack of Time

Other_______________________

3) How long have you been consistently physically active for? ______________

4) What activities are you presently involved in?

Cardio &/or Sports Frequency/Week Average Length Easy/Mod/Hard

________________ __________________________ _____________
________________ __________________________ _____________
________________ __________________________ _____________

Strength Training Frequency/Week Average Length Easy/Mod/Hard

__________________________ _________________ _____________

List exercises:___________________________________________________________
_______________________________________________________________________

Flexibility Frequency/Week Average Length

____________________________ ________________

4. If you could design your own exercise program, what would an ideal training week look like to
you? Please be specific. List your favorite activities, rest days, time spent etc.

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

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Goal Setting:
How can a Personal Trainer help you? Please check that which applies.

 Lose Body Fat  Develop Muscle Tone  Rehabilitate an Injury  Nutrition Education
 Start an Exercise Program  Design a more advanced program  Safety
 Sports Specific Training  Increase Muscle Size  Fun  Motivation
Other______________________________

In order to increase your chances of being successful at achieving your goals, a certain protocol
should be followed. Please ensure all your goals are ‘SMART’.
S= Specific (Provide details, how long, how much etc.)
M= Measurable (How will you measure whether you’ve reached your goals)
A= Attainable (Be realistic, set smaller goals)
R = Rewards-Based (Attach a reward to each goal)
T = Time Frame (Set specific dates for goals)
1. Please list in order of priority, the fitness goals you would like to achieve in the next 3-12
months?
a)__________________________________________________________________

b)__________________________________________________________________

c)__________________________________________________________________

2. How will you feel once you’ve achieved these goals? Be specific.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________________

3. Where do you rate health in your life?  Low priority  Medium Priority  High priority

4. How committed are you to achieving your fitness goals?  Very  Semi  Not very

5. What do you think the most important thing we can do to help you achieve your fitness goals?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________

6. Outline what you feel are the obstacles or your potential actions, behaviors or activities that
could impede your progress towards accomplishing your goals (i.e. not training consistently,
upcoming vacation, busy season at work, not following the program, allowing other responsibilities
to become a priority over exercise etc.).
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________________________________

7. Outline 3 methods that you plan to use to overcome these obstacles:

a. _______________________b. ________________________c.________________________

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