H M S Training
Physical Activity Readiness Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Date Of Birth
*
-
Month
-
Day
Year
Date
Emergency Contact
*
Name
Phone Number
Medical History
Do you have, or have you ever had a heart condition, high blood pressure or ciculatory problem?
*
Yes
No
If you answered yes, please elaborate.
Is there a history of heart disease in your family?
*
Yes
No
If you answered yes, please elaborate.
Do you experience pain in your chest when exercising or at rest?
*
Yes
No
If you answered yes, please elaborate.
Do you ever feel faint or suffer from dizzy spells?
*
Yes
No
If you answered yes, please elaborate.
Do you experience joint or back pain or suffer from a joint condition that could be exacerbated by physical activity?
*
Yes
No
If you answered yes, please elaborate.
Do you have diabetes?
*
Yes
No
Do you have asthma?
*
Yes
No
Do you suffer from epilepsy?
*
Yes
No
Have you had any surgery or medical procedure in the part year that may affect your physical activity?
*
Yes
No
If you answered yes, please elaborate.
Are you currently taking any prescribed medication?
*
Yes
No
If you answered yes, please elaborate.
Are you pregnant?
*
Yes
No
Please add any further medical information you feel should be shared prior to starting your exercise journey.
Disclaimer
To the best of my knowledge, information, and belief, I have no physical restriction which would prohibit my participation in this fitness class/ Personal training provided by H M S Training. I understand that I am responsible for monitoring my own physical condition throughout the exercise program and should any unusual symptoms occur, I would cease my participation and notify the instructor immediately. In signing this consent form, I acknowledge that I have read this waiver of liability and fully understand its terms. I agree to accept the risk of such exercise and further agree to not hold H M S Training and its instructors liable for any and all claims, suits, losses, or related cause of action for personal injuries or damages that may arise from my participation.
Signature
*
Thank you for taking the time to fill out this questionnaire. H M S Training looks forward to seeing you in class soon.
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