Physical Activity Readiness Questionnaire (PAR-Q) form and consent form for

Before any physical activity can begin please complete the following questionnaire by ticking either ‘yes’ or
‘no’.

Question Yes No
Has your doctor given any reason or advised that you may not participate in any physical exercise activity?
Have you been informed by your doctor that you have bone, joint problems e.g., arthritis that would be
aggravated or made worse by participating in physical exercise activity?

Are you new to exercise?

Do you have high blood pressure?

Do you have low blood pressure?

Have you ever been informed by a doctor that you have raised cholesterol?

Do you have a heart condition?

Have you ever felt chest pains when undertaking any physical activities and or exercise?

Are you currently taking any medication?

Do you or have you ever suffered from unusual shortness of breath with mild exertion?

Do you suffer from severe dizziness and or faint?

Are you asthmatic?

Are you diabetic?

Are you epileptic?

Are you pregnant?

If you have had a baby in the last 6 weeks has your doctor/midwife given you permission to commence
exercising?

Are you taking any medication from your doctor at present?

Do you know of any reason why you should not participate in any physical exercise activities?

More detail....

Please Read the Following Statements Carefully

I have read this form and its entirety and I understand my responsibility in future participation.

You may be required to seek approval by your doctor if you have answered ‘yes’ to any of the above questions on the
PAR Q form. We will recommend that you consult with your G.P prior to commencing any form of physical exercise
regime.

If you are injured during physical assessment or physical activity, the tutor will offer immediate first aid (if needed) but
will be unable to provide treatment. If injured, you will be responsible to seek treatment with your own physician or
primary care provider.

I hereby declare that there are no reasons why I may not participate in the physical activity exercises and I understand
that I am exercising at my own risk. Furthermore, I, for myself and my heirs, fully release from liability and waive all legal
claims against Diverse Trainers ltd and Instructors for injury or damage that I might incur during participation.

Signature: Date:
 Client Disclaimer

The purpose of an exercise programme is to help you achieve health and fitness goals

The programme will be based upon your present activity/exercise level and the goals that you wish to achieve.
You will experience some feelings of exertion during each activity session and will become hot and
uncomfortable at times. If your plan includes certain types of cardioid-vascular exercise. Your breathing and
heart rate will increase as a result of these activities as would be expected from physical exercise of this type.
As your fitness improves, you will participate in more vigorous levels of activity if this is part of your goal, but
these will be within your capabilities.

All activities will be explained and demonstrated but please feel free to ask questions about anything you wish.

Any exercise programme carries with it an element of risk. The sessions will be designed to minimise the risks
whilst providing an effective exercise/activity intensity. Please inform the instructor if, for any reason (such as
illness or injury which might be aggravated by exercise, or eating certain foods), you should not participate in
an activity.

If at any time, you feel undue pain or excessive discomfort, stop the activity and inform your trainer of your
symptoms, You are free to withdraw from any activity at any time you wish.

I agree to take part in the programme described to me by the instructor. The nature, purpose, risks and ben-
efits have been explained to me and I understand what is required of me and that I may withdraw at any time.

Client Signature:

Trainer Signature:

Date:
 Client Consultation
Name of client
Date of birth Gender M/F
Physical Activity Screening
What is your client’s occupation?

How does your client travel to and from their place of work?

Describe your client’s activity levels within their occupation.

Describe your client’s activity levels outside of their occupation.

Is your client engaging in any physical activity at present? Yes No

(team sport, individual sport, gym, running etc…)

If yes, please describe what is involved and how often a week they are exercising.

What are your clients exercise preferences?

When is your client available to engage in their exercise programme?
(days of the week, time of the day)

Height Weight BMI

Goal Setting
What are your client’s reasons for taking part in an exercise programme and what
would they like to achieve?

What are your client’s barriers to exercise?

Describe your strategy that you will adopt to help your client overcome these
barriers.

Explain how you will incorporate your clients exercise preferences into their
programme to strengthen their motivation and adherence.
What incentives or rewards will you use with your client to strengthen their
motivation and adherence?

Explain how will you encourage your client to take personal responsibility for their
own fitness/motivation and how will assist them to develop their own strategy for
motivation and adherence.

List the different behaviour change approaches/strategies you will adopt with
your client to encourage adherence to exercise/physical activity.

Using the SMART principle (Specific, Measureable, Achievable, Realistic, and Time-
bound) set out your clients’ short, medium and long term goals.
Short

Medium

Long
How will you review and revise your client’s short, medium and long term goals?

Short

Medium

Long

Clients signature Date

Instructor signature Date

 Your timetable should contain all information necessary for your client to have a basic
understanding of their training! Times, Estimated/Average RPE, Goal of session.
Remember, the information needs to be simplistic but informative at a glance.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

AM

PM
 8 Week Overview
Cardiovascular Training: Add 1 CV training modality to each column in the respective intensity!

MESOCYCLE 1 MESOCYCLE 2
WEEK 1 2 3 4 5 6 7 8
9-10

8-9

Intensity
RPE 7-8

6-7

<5-6
 8 Week Overview
This section requires you to give detailed justifications of your design desicions on a week-by-week basis

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8
 8 Week Overview

Resistance Training: Add 1 Resistance training modality to each column in the respective intensity!

MESOCYCLE 1 MESOCYCLE 2
WEEK 1 2 3 4 5 6 7 8
9-10

8-9
Intensity
RPE 7-8

6-7

<5-6
 8 Week Overview
This section requires you to give detailed justifications of your design desicions on a week-by-week basis

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8
 Programme card 1

Client’s name:

Safety checks required (detail checks carried out and any subsequent Any special arrangements or adaptations to be made (in response to
action taken): available time, equipment or facilities, or clients present on the day):

Location of nearest telephone: Location of nearest first aid kit:

Duty first aider:

Warm up: (appropriate stretches listed overleaf)

CV equipment / activity: Training system Time: Workload / target training zone: Teaching points:

Main CV component:
CV equipment / activity: Training system Time: Workload / target training zone: Teaching points:
Copyright © 2014 Active IQ Ltd. Not for resale
| 17
Main resistance training section
Exercise: Training system Equipment: Sets / reps: Teaching points:

Cool down (appropriate stretches listed below):

CV equipment / activity: Time: Workload / target training zone: Teaching points:

Warm up stretches (diagram and time to be held):

Cool down stretches in addition to above (diagram and time to be held):

Exercises / physical activities outside of the gym environment: Additional precautions or comments:
Programme card 2

Client’s name:

Safety checks required (detail checks carried out and any subsequent Any special arrangements or adaptations to be made (in response to
action taken): available time, equipment or facilities, or clients present on the day):

Location of nearest telephone: Location of nearest first aid kit:

Duty first aider:

Warm up: (appropriate stretches listed overleaf)

CV equipment / activity: Training system Time: Workload / target training zone: Teaching points:

Main CV component:
CV equipment / activity: Training system Time: Workload / target training zone: Teaching points:
Main resistance training section
Exercise: Training system Equipment: Sets / reps: Teaching points:

Cool down (appropriate stretches listed below):

CV equipment / activity: Time: Workload / target training zone: Teaching points:

 Warm up stretches (diagram and time to be held):
22 | Copyright © 2014 Active IQ Ltd. Not for resale

Cool down stretches in addition to above (diagram and time to be held):

Exercises / physical activities outside of the gym environment: Additional precautions or comments: