Physical Activity Readiness Questionnaire

Full Name*

First NameLast Name

Birth Date

MonthDayYear

EMAIL ADDRESS*

Phone Number*

Area CodePhone Number

Please read the following questions carefully and check (X) next to the appropriate answers. Answer all questions honestly and to the best of your ability.

YES/ NO*

	Yes	No
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or 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 your balance because of dizziness or do you ever lose consciousness?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

If you answered yes to any of the questions above, please explain:

Participation Agreement

I have voluntarily chosen to participate in the Fitness Program offered by Custom Fitness. I have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent me from participation. I acknowledge that participation is at my own pace and comfort level and that I may discontinue my participation at any time. Furthermore, I agree to self-determine my exertion through good judgement and to discontinue any activity that exceeds my personal limitations. I understand that by signing this agreement that I hereby waive and release Custom Fitness, LLC, its Board Members, staff, and all relevant employees in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation. I affirm that I have read and understand ths document and I wish to participate in fitness activities.

I hereby grant Custom Fitness permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

Signature of Participant:*

Type name of Participant*

Date*

MonthDayYear

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EMERGENCY CONTACT *

EMERGENCY CONTACT PHONE NUMBER*

Area CodePhone Number

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