Juicy Mountain PAR-Q

JUICE MASTER RETREAT QUESTIONNAIRE
Full Name*

First NameLast Name
Date of Retreat

DayMonthYear
Date
Birth Date*

DayMonthYear
E-mail*
Phone Number

Country CodePhone Number
Have you attended a Juice Master Retreat before?*
Are there any fruits or vegetables that you cannot consume?*
Do you have any allergies we should be aware of?*
Would you like to stop smoking whilst at the retreat?*
Would you like to drink less?*
PAR-Q Form

For most people, physical activity should not pose any problem or hazard. PAR-Q is designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.
1. Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise?*
2. Do you have high blood pressure?*
3. Do you have low blood pressure?*
4. Do you have Diabetes Mellitus or any other metabolic disease?*
5. Has your doctor ever said that you have raised cholesterol (serum level above 6.2mmol/L)?*
6. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by your doctor?*
7. Have you ever felt pain in your chest when you do physical exercise?*
8. Is your doctor currently prescribing you drugs or medication?*
9. Have you ever suffered from unusual shortness of breath at rest or with mild exertion?*
10. Is there any history of Coronary Heart Disease in your family?*
11. Do you often feel faint, have spells or severe dizziness or have lost consciousness?*
12. Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)?*
14. Are you, or is there any possibility that you might be pregnant?*
15. Do you know of any other reason why you should not participate in a programme of physical activity?*
If YES please give details:
Additional note: I have taken medical advice and my doctor has agreed that I should exercise (if applicable):*
If you answered:- YES to one or more questions:
If you have not recently done so, consult with your doctor by telephone or in person before attending the retreat. Tell you doctor what questions you answered ‘yes’ to. After medical evaluation, seek advice from your doctor as to your suitability for: Physical activities ranging from mountain walks/runs, yoga, mini trampolining, cardio and toning fitness classes.
As a regular and returning guest (if applicable) of Juice Master Ltd, I hereby accept this form to be held on file by Juice Master for all future retreats. I confirm that I will notify Juice Master if anything changes in terms of my health and fitness as mentioned on this form. I confirm the above information is accurate and that I acceptance the terms and conditions noted on the Booking Confirmation for this Detox Retreat. Assumption of Risk I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise and stretching, such as yoga, Pilates, running, power walks, mini trampolining, volley ball, sauna, swimming, gentle walks and rambles. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.*
Signed (Name)*

Clear
Date:*

DayMonthYear
If you wish to have this form emailed to you, so that you can return it by post please contact the team on mountain@juicemasterretreats.com.
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JUICE MASTER RETREAT QUESTIONNAIRE

PAR-Q Form