Client Questionnaire

Client Information
Full name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Date of Birth *
E-mail*
Phone Number*

Area CodePhone Number
Emergency contact*

First NameLast Name
Phone number*

Area CodePhone Number
Health Questionnaire (Par-Q)
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when performing physical activity?
In the past month, have you had chest pain when you were NOT performing physical activity?
Do you lose balance because of dizziness or have you lost consciousness recently?
Do you have bone, muscular or joint conditions (for example, arthritis, back, knee, or hip) that could be aggravated through physical activity?
Is your doctor currently prescribing you medications for blood pressure or heart condition?
Are you diabetic or asthmatic?
Do you know of any other reason why you should not do physical activity?

If you have answered YES to any questions above please provide details:
I have read, understood and accurately completed this questionnaire. All questions I had were answered to my full satisfaction.
Initials*

Clear
Client information - Liability Waiver
I am aware of the risks in observing or participating in the activities offered by Karen James and fully understand that all classes I participate in are entirely at my own risk. I assume complete responsibility and liability for those risks and for any injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, and or my property.
Initials*

Clear
Client information - 24h cancellation policy
All cancellations must be received at least 24h before your class in order to avoid being charged. Clients who do not cancel with 24h notice will be charged 50% of a regular price session for the cancellation.

Karen James understands that emergencies happen and will provide every client with one free short-notice cancellation. You will not be charged for your first cancellation with less than 24h notice. Subsequent short notice cancellations will be charged for the session. The free short-notice cancellation only applies if Karen James receives notice prior to the session start time. No shows are not eligible for the free cancellation.
Initials*

Clear
Client Signature
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Client Information

Health Questionnaire (Par-Q)

Client information - Liability Waiver

Client information - 24h cancellation policy

Client Signature