PAR-Q: Gym Health Form

Full name*

First NameLast Name

Birth Date

DayMonthYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

Phone Number*

Area CodePhone Number

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone number*

Area CodePhone Number

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 you do physical activity?
In 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 worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Are you pregnant or have given birth in the past 6 months?
Do you have any injuries?
Do you take any medication?
Do you suffer from back pain?

Please provide any further details here:

I have read, understood and completed this questionnaire to the best of my knowledge.

Initials*

I am aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in a physical activity.

Having such knowledge, I hereby acknowledge this release, any representatives, agents and successors from liability for accidental injury or illness which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program.

Initials*

Date

JourMoisAnnée

Client Information

Health questionnaire (Par-Q)

Liability waiver