FIT by J.D. PAR-Q / Terms & Conditions

FIT by J.D. PAR-Q / Terms & Conditions

Please complete and sign the following: Physical Activity Readiness Questionnaire / Terms & Conditions.
Full Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Age*
Years
Gender*

MaleFemale
Height*
Feet ' Inches "
Weight*
Pounds
Emergency Contact Name & Phone Number
John Doe 555-555-5555
PAR-Q

Physical Activity Readiness Questionnaire

Please answer the following questions by selecting YES or NO:*

	YES	NO
Has a doctor ever said that you have a heart condition and that you should only participate in medically supervised physical activity?
Do you have or feel chest pain during physical activity?
Do you experience any loss of balance due to dizziness or do you lose consciousness?
Are you taking any medication for high blood pressure or a heart condition?
Do you have any existing bone or joint problem that is likely to be made worse by an increase in physical activity?
Do you experience shortness of breath with MILD exertion?
Do you suffer from palpitations?
Are you pregnant or have you given birth in the last 6 weeks?
Do you knowingly have diabetes mellitus?
Are you aware of any other reason why you should not exercise without medical supervision?

If the answer to any of the above questions is YES, you will need to get consent from your physician prior to participating in any program of activity.

Please answer the following questions by selecting YES or NO:*

	YES	NO
Is your blood pressure known to be high?
Is your cholesterol level known to be high?
Do you smoke?
Is there a history of heart or coronary artery disease in either your parents or siblings before the age of 55?

If you have answered YES to 2 or more of the above questions, your exercise program will, for safety reasons, be restricted to a moderate intensity, unless consent has been given by a doctor to work at a higher intensity. Moderate intensity will be defined as a level at which you are able to comfortably sustain exercise for up to at least 60 minutes.
15. Is there any other physical reason not mentioned above that would prevent you from beginning an exercise program? *

YESNO
If YES, please give details:
Client PAR-Q Declaration*

I hereby declare that I have answered the above PAR-Q truthfully and to the best of my knowledge. I declare that I have received consent from my physician to participate in an exercise and/or nutrition program. Should any circumstances arise that may change my responses to any items addressed above, I will inform my trainer prior to engaging in an exercise session.
Client Signature*
[Use mouse or finger as a pen to sign above.]

By signing above, I hereby declare that I have answered the above PAR-Q truthfully and to the best of my knowledge. I declare that I have received consent from my physician to participate in an exercise and/or nutrition program. Should any circumstances arise that may change my responses to any items addressed above, I will inform my trainer prior to engaging in an exercise program.
Client Agreement

I have read and agree to all Terms & Conditions.
Client Signature*
[Use mouse or finger as a pen to sign above.]

By signing above, I agree to all FIT by J.D. LLC Terms & Conditions.
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