PAR-Q for FOOD AND FITNESS BY LOUISE

PAR-Q for FOOD AND FITNESS BY LOUISE
First Name *
Last Name *
Email Address *
Phone Number
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?

YES NO
Do you frequently have pains in your chest when you perform physical activity?

YES NO
Have you had chest pain when you were not doing physical activity?

YES NO
Do you lose your balance due to dizziness or do you ever lose consciousness?

YES NO
Are you pregnant now or have you given birth within the last 6 months?

YES NO
Have you had a recent surgery?

YES NO
Do you have any chronic illness or physical limitations such as Asthma, diabetes?

YES NO
Do you have any injuries or orthopedic problems such as bursitis, bad knees, back, shoulder, wrist or neck issues ?

YES NO
If you have answered YES to any of the above questions, please provide further details
Do you have any of the following medical conditions?
If you answer Other, please provide further details below
Do you take any medications, either prescription or non-prescription, on a regular basis?

YES NO
If you answered YES to taking medication(s), please give details:
How does this medication affect your ability to exercise or achieve your fitness goals?
ASSUMPTION OF RISK AND CONSENT: I, the Client, have been informed, understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment are potentially hazardous activities. I also have been informed, understand and am aware that fitness activities involve a risk of injury and that I am voluntarily participating in these activities and using equipment with full knowledge, understanding and appreciations of the dangers involved. I understand that precautions will be used during this evaluation/training program to prevent physical injury to me. However, in the event of physical injury resulting from the fitness evaluation procedures, equipment usage or training protocols, no medical treatment or monetary compensation will be provided by Food and Fitness by Louise . I assume the full risk associated with the participation in the training programs and agree to hold harmless Food and Fitness by Louise and all employees associated with this company. I acknowledge that Food and Fitness by Louise is relying solely on information provided by me regarding my medical history and physical condition, in allowing me to participate in any evaluation or training session. I certify that I have made a complete disclosure of my medical history and physical condition, and that the information provided is true and correct.

I have read the assumption of risk and consent
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