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

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 have any current or recent injuries which may affect your ability to train?
Do you current take any regular medication?
Do you have diabetes?
Any Pulmonary (lung) problems?
Heart problems or heart surgery?
High blood pressure?
Low blood pressure?
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

(sign with finger)

I declare that all the information given above is accurate and up to date and I will notify David Richard prior to training if there are any changes to any of the questions above.

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

(sign with finger)

All cancellations must be received at least 24hrs before your class or training session in order to avoid being charged. Clients who do not cancel with 24hrs notice will be still be charged full price per session for the cancellation.

I understand that emergencies happen. So I provide every client with one free short-notice cancellation. You will not be charged for your first cancellation with less than 24hrs notice. Subsequent short notice cancellations will be charged for the session.No shows are not eligible for the free cancellation.

Initials

(sign with finger)

Date

JourMoisAnnée

Client Information

Health questionnaire (Par-Q)

Liability waiver

24hr Cancellation Policy