Gym health questionnaire Form

Full name*

First NameLast Name

Date of birth*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityCounty

Post codeCountry

E-mail*

Phone Number*

Area CodePhone Number

Emergency contact*

First NameLast Name

Phone number*

Area CodePhone Number

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 exercise
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 worsened by physical activity?
Are you currently taking any medication for high blood pressure?
Do you know of any other reason why you should not partake physical activity?

I have read, understood and completed this questionnaire.

By my signature below, I understand that Mama Be Fit instructors and the facilities where classes and PT sessions are held assume no responsibility for injuries or illnesses which I may sustain as a result of my physical condition or resulting from participation in a class or PT session, and/or from the use the equipment at the facility. In addition, I understand that I should consult with my physician before beginning any physical activity. I expressly acknowledge that I assume the risk for any and all injuries and illnesses, which may result from participation in any session or class offered by Mama Be Fit I hereby release and discharge the instructor and the facility from any and all claims for injury, illness, death, loss or damage, which may result from my participation in Mama Be Fit sessions.

I declare the above information is correct and will inform you of any changes in the future:

Signature and date*

Heath Questionnaire (Par-Q)