Client InformationFirst Name *Last Name *Street Address *City *State/Province *ZIP / Postal Code *Country *Select countryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaSouth Georgia and South SandwichGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaNorthern Mariana IslandsMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaStateless PersonsSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweOccupationOccupation *0 / 180How many days/week do you work *How many hours/day do you work *Does your occupation require you to travel often? *YesNoContact InformationEmail Address *Phone Number *0 / 180Do you give PF4U Coaches permission to CALL or TEXT the phone number provided above? *YesNoHow did you hear about #PF4UIf you were referred, tell us who. We'd love to thank them!Health InformationAge *0 / 180Height *0 / 180Weight *0 / 180Body Fat Percentage (if known)0 / 180Do you own a smart watch? If so, what kind of watch?0 / 60How active/sedentary will your typical day be on a scale from 1-10 (1-sedentary, 10- highly active)? *12345678910Are you within 5 days of your last period? *YesNoUnsureN/AAre you pregnantYesNoN/AAre you breastfeeding?YesNoDo you suffer from any chronic medical conditions?Do you take any medications, either prescription or non-prescription, on a regular basis? *Please list condition(s) and medications0 / 180Do you smoke? How many times per day?0 / 180Do you drink alcohol?How many drinks per week (on average)?0 / 180How many hours of sleep do you receive PER night (on average)? *0 / 180What are your favorite activities/hobbies? *0 / 180On a scale of 1-5, how do you rate your health as a priority *12345(1=worst, 5=best)On a scale of 1-5, how does your support system rate your health as a priority in their lives *12345(1=worst, 5=best)Training InformationOn a scale of 1-10, how would you rate your current fitness level? *12345678910(1=worst, 10=best)How often do you take part in physical exercise? *Number of times/week and how long/session.0 / 180What kinds of activity do you currently complete? *0 / 180How often would you REALISTICALLY like to exercise during your program? *A.) Number of times per week? B.) Time (minutes) per session?0 / 180Do you currently have or plan on obtaining a gym membership while participating in your Perfectfit4u program? *YesNoGym membership?If you answered YES to the previous question, what GYM do you have a MEMBERSHIP too?Do you prefer to execute ALL of your workouts at the home? *YesNoDo you prefer to execute SOME of your workouts at home and SOME of your workouts at the gym?a. How many days at home? b. How many days at the gym?Do you have any equipment available at home?0 / 180Please list, in order of priority, the TRAINING goals you would like to achieve through this program.Nutrition InformationOn a scale from 1-5, how would you rate your CURRENT nutrition/eating habits? *12345(1=Poor, 5=Excellent)Do you have any food ALLERGIES? *YesNo (Ex. Celiac, Lactose Intolerance, etc.)Please explain below0 / 180Please let us know by checking the box of the food you may have taste aversions too:Chicken BreastTurkey BreastEggsEgg WhitesCodShrimpCanned TunaHalibutSalmonBeefYogurtCottage CheeseProtein PowdersProtein BarsOatsCream of WheatCerealRice CakesCrackersRiceQuinoaCouscousMilletSweet PotatoWhite PotatoPastaBreadBeansBerriesBananaPineappleMelonSeedsNutsNut ButterAvocadoCream CheeseOlive OilCocanut OilWhat are some of your favourite or most highly consumed foods on a daily basis? *0 / 180How many times throughout the day do you currently eat (on average)? *0 / 180Please describe your daily eating schedule/routine.Do you tend to skip meals despite being hungry? *YesNoSometimesDo you eat breakfast religiously? *YesNoDo you tend to eat late at night? *YesNoDo you have a preferred dieting method that has been proven to work for you in the past? *If so, please explain (Ex. Paleo, Vegan, Vegetarian, etc.) Feel free to explain further if needed. 0 / 180Have you ever tracked your food intake? *YesNo(i.e. food diary)How familiar are you with "macros" and "macro counting"? *12345(1=Poor, 5=Excellent)Do you do your own grocery shopping? *YesNoHow important is it for you to be able to cook meals for your family members? *12345(1=not very, 5=every meal)What appliances do you have at your disposal for food preparation on a typical weekday? *(i.e. Stove, Oven, Toaster, Blender, Microwave, etc.)0 / 180How many liters of water do you consume daily? (on average) *0 / 180Are you currently taking specific vitamins or any other supplements? *YesNoPlease include them here:Please list, in order of priority, the NUTRITION goals you would like to achieve through this program.MiscellaneousDescribe your ideal coach or what exactly you'd expect from an ideal coach *0 / 180Would you like a membership to the Perfectfit4u App which includes a PRO membership that allows clients to track their food intake and body metrics/progress as well as receive access to workout demo videos of their programs. Login information will be provided with your first program. *YesNo(for iPhone or Android) for $3.99/month?Please list anything that you may feel is a concern or information that has not been disclosed that you feel our staff should know in order to develop the program best suited for you.0 / 180Start PhotosDo you have your start photos ready for upload? If so, upload them below. If not, please email front, back and side profile photos to info@perfectfit4u.caFrontChoose FileNo file chosenDelete uploaded fileBackChoose FileNo file chosenDelete uploaded fileSideChoose FileNo file chosenDelete uploaded filePARQPhysical Activity Readiness QuestionnaireHas your doctor ever said that you have a heart condition or high blood pressure? *YesNoDo you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity? *YesNoDo you lose balance because of dizziness or have you lost consciousness in the last 12 years? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *YesNoHave you ever been diagnosed with another chronic medical condition? *YesNoPlease describe:Are you currently taking prescribed medication for a chronic medical condition?YesNoPlease describe:Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. *YesNoHas your doctor ever said that your should only do medically supervised physical activity? *YesNoDatePlease select today's date.By checking this box, your are eSigning this form.I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed, and become invalid if my condition changes. I also acknowledge that #Perfectfit4u may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.Submit
