Health Questionnaire
A PAR-Q is a self screening that can and should be used for anyone who is planning to start an exercise program. All questions are designed to help uncover any potential risks associated with exercise.To ensure your health and safety is prioritised please answer the questions as honestly as you can. Once the form has been reviewed, you may need to obtain clearance from your doctor before starting BixFit Bootcamp.
Full Name
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First Name
Last Name
Contact Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
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Date Of Birth
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-
Month
-
Day
Year
Date
Emergency Contact Name
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Emergency Contact Number
*
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General Health Questions
1. Has your doctor ever said that you have a heart condition or recommended that you only perform physical activity under medical supervision?
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Yes
No
2. Do you feel pain in your chest when you perform physical activity?
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Yes
No
3. In the past month, have you experience chest pain when not performing physical activity?
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Yes
No
4. Do you lose your balance because of dizziness of ever lose consciousness?
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Yes
No
5. Do you have a bone, joint, or muscle problem that could be made worse by physical activity? If yes please specify in next box
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Yes
No
If answered yes for the previous question, please explain further with estimate date of when the issue started.
6. Are you currently taking medication for blood pressure or a heart condition?
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Yes
No
7. Do you have any other medical conditions that might affect your ability to participate in physical activity? (e.g asthma, diabetes, epilepsy or any other chronic condition)?
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Yes
No
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Lifestyle and Exercise History
8. Are you currently physically active?
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Inactive
Somewhat Active
Active
Very Active
9. Do you smoke or have you smoked in the past 6 months?
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Yes
No
10. Do you have any previous experience with ground fitness or bootcamp style training?
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Yes
No
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Injuries and Conditions
11. Do you have any current injuries? (eg back, shoulder, knee)? If Yes please specify:
12. Do you have any medical conditions? Such as (Diabetes, Asthma etc) If Yes please specify below
13. Have you had any surgeries in the past 12 months?
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Yes
No
14. Do you experience joint pain, swelling, or stiffness that affects your daily activities?
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Yes
No
15. Do you experience joint pain, swelling, or stiffness that affects your daily activities?
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Yes
No
16. Do you experience joint pain, swelling, or stiffness that affects your daily activities?
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Yes
No
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Additional Questions
17. Are you currently pregnant or have you given birth in the past 6 months?
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Yes
No
18. Please list any concerns not covered above that might affect your participation in BixFit Bootcamp
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Consent and Acknowledgment
I understand that it is my responsibility to provide accurate information and inform BixFit Bootcamp of any changes to my health or fitness levels.
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I agree
I acknowledge that participation in physical activity carries some risk, and I agree to take part at my own risk.
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I agree
I understand that I may be required to obtain clearance from my doctor before beginning the programme if any issues are identified during this screening process.
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I agree
I acknowledge that Georgia Bixley and BixFit Bootcamp are not liable for any injury, illness, or death that may occur during or as a result of my participation in the programme.
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I agree
I give my consent to receive email and/or other contact from BixFit (Georgia Bixley) following the review of my questionnaire.
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I agree
I have read, understood, and agree to the terms and conditions outlined above including the acknowledgment of risk and the disclaimer liability.
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I agree
Signature
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Signature For Trainer
Date
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-
Month
-
Day
Year
Date
Submit
Should be Empty: