Health Questionnaire Form for Dynalistic Wellbeing Fitness Classes

Welcome sheet - Client information
Full name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
Emergency contact*

First NameLast Name
Phone number*

Area CodePhone Number
Clients informations - 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 fain in your chest when you do physical activity?
n the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction

If I have answered yes to any of the questions further information will be emailed to the instructor asap and before the first class I attend

I confirm that I will not attend an in person / live class (outdoors & indoors) if I experience or have been in contact with someone who has experienced any of the following symptoms up to 10 days prior to the class : high temperature, new persistent cough, loss of taste & smell.

I confirm that I will not attend a class if I have been asked to self isolate, received a positive Coronavirus test result or been in contact with someone who has either or both of the same in the 10 days prior to a class. I shall inform the instructor asap and will be given a credit towards my next available class.
Initials*

Clear
Client informations - Liability waiver
I warrant that I am to the best of my knowledge medically fit and healthy to take part in classes offered by Dynalistic Wellbeing for which I am attending. I am aware of the risks in observing or participating in the activities offered by Dynalistic Wellbeing and I understand that all exercise programmes that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the 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 or damage to my property.
Initials*

Clear
Client informations - Signature
Signature*

Clear
Date

JourMoisAnnéehi me messaoudMinutesAM/PM Option
Should be Empty:

Welcome sheet - Client information

Clients informations - Health questionnaire (Par-Q)

Client informations - Liability waiver

Client informations - Signature