PAR-Q: Gym Health Form

PAR Q
Full name*

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Address*

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E-mail*
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Emergency Contact Name*

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Health questionnaire (Par-Q)
Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q*

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 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 currently 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*

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Liability waiver
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.

I understand I am voluntarily participating in physical activity within Flexability Fitness.

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.
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