Brooks Fitness PAR-Q & Informed Consent

Name*

First NameLast Name

Date of birth*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Phone Number

Email*

example@example.com

Emergency contact*

Full name

Emergency contact number*

Phone or mobile number

COVID-19

Due to the infectious nature of COVID-19, this additional health information must be asked as part of pre-exercise participation health & safety documentation. Please be aware that people who have COVID-19 can be asymptomatic and still be contagious. There is no way we can completely protect ourselves from this virus, however, Brooks Fitness is taking the following measures to minimise risk. Which includes enforcing social distancing measures, thorough sanitisation of equipment before and after use, encouraging the use of hand sanitiser before, during and after sessions, no handling of cash payments and verbal pre-screening of all clients for symptoms prior to each session. Your information will be held on file (private & protected) and used to contact you for Track & Trace, should anyone present with COVID-19 that has been in close contact in classes/PT sessions.

Please answer the following questions truthfully and please adhere to our new measures so we can do our best to protect each other.

YesNo

If YES, when, what test have you had and what were the results?

YesNo

Detail any further info related to COVID-19 below

Further detail

Signature*

Today's date*

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

This PAR-Q is designed to help you to help yourself. Many benefits are associated with regular exercise, and completion of the PAR-Q form is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people physical activity should not pose a problem or hazard.

The PAR-Q has been designed to identify a small number of people for whom physical activity might be inappropriate or for those who should seek medical advice concerning the type of activity most suitable for them. Common sense is your best guide for answering these questions. Please read the questions carefully and answer each one honestly, YES or NO.

Health questions*

Rows	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 you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart conditions?
Do you know of any other reason why you should not do physical activity?
Are you allergic to latex?

Do you have any other medical conditions and/or injuries we need to be aware of?

Further detail

If you have answered YES to any of the above questions, then you are required to gain consent from your doctor before participating in exercise.

If you answered NO to all of the above questions and you have reasonable assurance of your suitability for exercise, you can start becoming more physically active – begin slowly and build up gradually, this is the safest and easiest way to go.

PLEASE NOTE

Delay becoming more active / exercising if you are not feeling well because of a temporary illness such as a cold or a fever, wait until you feel better. If your health changes so that you then answer YES to any of the above questions, inform the fitness instructor and/or health professional. Ask whether you should change your physical activity plan.

PRE & POST NATAL WOMEN TAKING PART IN EXERCISE (COMPLETE IF APPLICABLE)

Pregnant: If you are pregnant you must be at least 12 weeks to take part in classes and not be suffering with any of the following contraindications.

Pregnancy related contraindications (that would mean exercise is NOT advised). Please state YES or NO to each condition listed below:

Rows	Yes	No
Hemodynamically significant heart disease
Restrictive lung disease
Incompetent cervix
Multiple gestation
Persistent bleeding
Placenta previa (after 26 weeks)
Premature labour
Ruptured membranes
Pregnancy induced hypertension
Pre-eclampsia

Postnatal: You must have been signed off by your GP and/or midwife and given the OK to start exercising and take part in classes. This usually happens between 6-12 weeks after you have had your baby, depending on the type of delivery you had and your recovery.

Is there any additional information we need to be aware of for your pregnancy / postnatal recovery?

Further detail

Signature*

Today's date*

INFORMED CONSENT

Informed consent for exercise participation

I understand that the purpose of the exercise participation is to provide safe and individualised exercise to improve health and fitness. I understand that exercises will consist of one or more of the following components:

Cardiovascular – treadmill walking/jogging/running, rowing, upright or recumbent cycling, stair climbing, various body weight exercises and other such activites in outdoor environments.
Resistance – using resistance machines, free weights, resistance bands or circuit training to improve muscular strength and/or endurance.
Mobility and flexibility exercises to improve core stability and movement around the joints and range of motion.
General physical activities.
Physical assessments and measurements.

Potential Risks

The exercise programme is designed to place a gradually increasing workload on the cardiovascular and muscular systems and thereby improve their function. The reaction of the cardiovascular and muscular systems to such exercise cannot always be predicted with complete accuracy. There is a risk of certain changes that might occur during or following the exercise. These changes could relate to blood pressure or heart rate. I willfully assume these risks.

I understand that I may stop or delay any exercise if I so desire, and that the training session may be terminated by the fitness instructor upon observation of any symptoms of undue distress or abnormal response. Including my obligation to immediately inform the fitness instructor of any abnormal symptoms that I may suffer whilst exercising.

I understand that I may ask any questions or request further explanation or information about the exercises/procedures at any time before, during and after training.

I have read, understood, and completed the OCVID-19 and medical screening questionnaire (PAR-Q) and obtained medical clearance, if necessary.

I hereby release the fitness professional from any liability with respect to any damage or injury (including death) that I may suffer whilst exercising.

Signature*

Today's date*

PLEASE NOTE

Should any of the above information you have given change; personal and/or emergency contact details, COVID / health status. Please inform the instructor, you will also be required to complete this form again, so that it is current and up to date.

Many thanks and happy training!

Kate & Ruth x

Brooks Fitness PAR-Q & Informed Consent

Personal details