HEALTH FORM
please print out – fill in and bring to your first class
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Physical Activity Readiness Questionnaire – Bodysmart Fitness CLASSES WITH HELEN BAKER AND KAREN BUCK |
| Please read the questions carefully and answer each one honestly, highlight the appropriate answer & add information if necessary. Your responses will of course be kept in the strictest of confidence. This form must be completed before commencement of your first class.
Name ____________________________ Email__________________________________________ (If you give an email address you will be added to my mailing list to receive info on promotions and any class changes or cancellations) Emergency Contact no ___________________________ HOW DID YOU HEAR OF THIS CLASS? _________________________________________________________ Do you suffer from any joint or bone problems that could be made worse by increasing your physical activity? Yes/No Do you have high pressure? Yes/No Do you suffer from diabetes? Yes/No Do you have a heart condition? Yes/No Do you take prescribed drugs for health reasons? Yes/No Do you feel dizzy/lose your balance/ever lost consciousness? Yes/No Are you pregnant or have you had a baby in the last six months? Yes/No Do you know of any other reason why you should not do physical activity? Yes/No If YES please give details _______________________________________________ If you answered: YES to one or more questions and have not recently done so, consult with your doctor by telephone or in person before increasing your physical activity. Tell you doctor what questions you answered ‘yes’ to on the PAR-Q. After medical evaluation, seek advice from your doctor as to your suitability for: 1) Unrestricted physical activity starting off easily and progressing gradually and 2) Restricted or supervised activity to meet your specific needs, at least on an initial basis. NO to all questions: If you answered PAR-Q accurately, you have reasonable assurance of your present suitability for a general fitness class 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. 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. Additional note: I have taken medical advice and my doctor has agreed that I should exercise. Signature:____________________________________ Date: _________________ |
