Waiver of Liability and Release Form
Upon reading and your agreement, please sign NAME and DATE, along with your address
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
*
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Exercise Readiness Questionnaire - PAR-Q
Ensure all information below is accurate and updated if there is any change to your health status.Safety of all members within the gym is of paramount importance. For this reason we must establish your current health status prior to helping you improve your fitness. The questions below are designed to identify those persons who should obtain medical advice before undertaking physical exercise and will also help us to prescribe the most effective fitness programme for you. Whilst every care will be given to the best of of the gym teams ability, it is up to the individual to know his/her limitations. All information will be treated with the strictest confidence, this form will be stored in a secure and protected drive.
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Contact Number
*
Email
*
example@example.com
Emergency Contact Name and Phone Number
*
GP Surgery Name
*
Has your GP ever diagnosed a heart condition or recommended medically supervised only exercise?
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Yes
No
Do you suffer from chest pains, heart palpitations or tightness of the chest?
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Yes
No
Have you been seeking medical attention for any other conditions?
*
Yes
No
If you have answered 'YES' to any of the questions above, please give brief details. If No, put N/A
*
Do you have known high blood pressure?
*
Yes
No
If 'YES', please give details i.e. medications etc
*
Do you have low blood pressure or often feel faint or have dizzy spells?
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Yes
No
Have you ever had any bone or joint problems, which would be aggravated by physical activity?
*
Yes
No
Do you suffer from diabetes? If 'YES', are you insulin dependent? If No, put N/A
*
Yes
No
Do you suffer with any chest problems i.e. asthma, bronchitis, emphysema?
*
Yes
No
Do you suffer from Epilepsy? If 'YES', when did you last have a fit? If No, put N/A
*
Are you pregnant or have you recently had a baby?
*
Yes
No
Have you participated in any regular exercise in the past?
*
Yes
No
Are you on any medication or have you recently had any illness?
*
Yes
No
If you have answered 'YES' to any of the questions above please give brief details. If No, put N/A
*
Have you had any injuries in the past, e.g. back problems or muscle, tendon or ligament strains etc?
*
Yes
No
If 'YES', please give details of injuries. If No, put N/A
*
What Type of Trainer Are You?
Completely New
Know Enough To Get By
Confident/Experienced
Advanced/Professional/Coached
What Goals Are You Working Towards?
Weight Loss/Body Composition
Gain Strength
Physical Health (Blood Pressure etc)
Performance (Sport)
Injury Rehab/Recovery
Is there any other reason, not already mentioned, which may affect your ability to exercise?
*
I have read and fully understand the Exercise Readiness Questionnaire - PAR-Q. I confirm, to the best of my knowledge, the answers given are correct and accurate. I know of no reason, unless stated otherwise above, why I should not participate in an exercise workout. I understand that I would be using the gym entirely at my own risk and waive any legal resource for damages to myself or property arising from my participation. (Sign Below)
*
Submit
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