PAR-Q: Gym Health Form

Client Information
Full Name*
Full 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 Information
Spouse Name

First NameLast Name
Spouse Phone number

Area CodePhone Number
Other Emergency Contact Name*

First NameLast Name
Othrt Emergency Contact Phone number*

Area CodePhone Number
Emergency Contact Relationship*
Relationship
Health questionnaire (Par-Q)
Enhance overall well-being and vitalityIncrease self-awareness and inner harmonyReduce levels of stress and anxietyReverse aging process and improve biological ageAchieve mental and physical balanceImprove flexibility and muscle strength
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 blood pressure or heart condition?
Do you take any medication?
Do you suffer from back pain?
Are you sexually active? If not, please skip the next section

Sexual Activity
0 - 56 - 10more than that
YesNo
Please provide any further details here:
Liability waiver
By participating in the comprehensive wellness program offered by Zen Wellness Therapy Center, I acknowledge that my involvement is voluntary and that I have provided accurate health information. I understand and accept the inherent risks associated with activities such as yoga, osteopathy, chiropractic sessions, chakra opening sessions, walking, water cycling, dead sea trips, meditation, nutritional programs, and sound healing. I release Zen Wellness Therapy Center, its employees, instructors, contractors, and affiliates from any liability for injury, loss, or damage incurred during the program. I confirm that I have obtained medical clearance to participate and grant permission for the use of any media captured during the program.
Should be Empty:

Sexual Activity