Online Client PARQ





PERSONAL INFORMATION

Name (required)

Address

Phone Number

Email Address

Emergency Contact Name and Number

Height

Weight

Date of Birth

HEALTH QUESTIONNAIRE

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly.

  1. Has your Doctor ever said you should NOT take part in physical activity? YesNo

  2. Has your Doctor ever said that you have a heart condition? YesNo

  3. Has your Doctor ever said that you have high/low blood pressure? YesNo

  4. Are you taking any medication for your blood pressure or heart condition? YesNo

  5. Do you have Diabetes Mellitus or any other form of Diabetes? YesNo

  6. Do you, or have you recently felt pain in your chest when doing physical activity? YesNo

  7. Do you ever lose balance, become dizzy or ever lose consciousness? YesNo

  8. Do you have any injuries that could be aggravated by exercise? YesNo

  9. More specifically, do you have any joint problems including back, knees and/or neck? YesNo

  10. Has anyone in your immediate family had a heart attack prior to the age of 55 years? YesNo

  11. Has your Doctor ever said you have raised cholesterol levels? YesNo

  12. Have you ever been short of breath, had difficulty breathing or been diagnosed with asthma? YesNo

  13. Do you suffer from Epilepsy? YesNo

  14. Are you or do you think you may be, pregnant? YesNo

  15. Have you had or are you in recovery from any major surgery including pregnancy in the last 6 months?
    If yes please give details below. YesNo


Is there any other reason, medical or otherwise that may affect your ability to exercise? If yes, please comment below

DECLARATION

I understand that if my health changes so that I then answer YES to any of the above questions, I will inform my trainer and ask whether I should change my physical plan.

I understand that Reach Fitness / The Real Fitness Coach / Danny Sroda strongly advise that if I have not participated in regular physical exercise prior to beginning this activity, I should seek advice from my doctor.

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 such as running, jumping and rowing, resistance exercise (including but not limited to barbells, dumbbells, kettlebells and various weight-training equipment) and stretching. 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, and that I should consult my doctor if I am suffering from any condition that might make physical activity injurious to my health.

I understand that the responsibility of my fitness to participate rests with me. I agree to abide by any verbal or written instruction given by my trainer. I declare that to the best of my knowledge this information is correct and that I will notify my trainer of any changes in my medical condition.

I understand the results of any fitness program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions.

I understand that Reach Fitness / The Real Fitness Coach / Danny Sroda may use progress photographs for promotional purposes and I agree to allow them to use these pictures, films, and/or likenesses of me for these promotional purposes. In the event I choose not to allow the use of the same for said purpose, I agree that I must inform Reach Fitness / The Real Fitness Coach / Danny Sroda of this in writing.

I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my Trainer.

I agree that Reach Fitness / The Real Fitness Coach / Danny Sroda shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge Reach Fitness and its owners, employees, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators and assigns.

I Agree that I have read and agree to the statements above