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Client's personal information.

Please take a moment to fill out the form.

Emergency Contact

Motivation & Factors

How would you describe your current fitness level?

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Physical Activity Readiness Questionnaire (PAR-Q)
Please read each question carefully and circle YES Or NO
Has your doctor ever said that you have a heart condition and 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?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) 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 one or more questions:

You should consult your doctor before increasing your physical activity or taking part in a
fitness assessment. Tell your doctor which questions you answered “Yes” to.

Client Declaration

I have read, understood, and answered this questionnaire honestly. I confirm that I am
voluntarily engaging in physical activity and accept responsibility for my own health and
safety.

Thanks for submitting!

INFORMED CONSENT FORM

Please take a moment to fill out the form.

Consents to participating in the fitness assessment and testing on the
following terms:

The test procedures have been explained to me and I understand what I will be required to do.
I understand that I will be taking part in physical exercise at or near the extent of my capacity and that there is a
possible risk in the physical exercise at that level, i.e. episodes of light-headedness, fainting, abnormal blood pressure,
chest discomfort, and nausea.
I understand that this may occur though the instructor will take all proper care in the conduct of the assessment,
and I will fully assume that risk.
I understand that I can withdraw my consent, freely and without prejudice, at any time before, during, or after testing.
I have completed the physical activity readiness questionnaire (PAR-Q) and have told the person conducting the test
about any illness or physical defect I have that might contribute to the level of that risk.
I understand that the information obtained from the tests will be treated confidentially with my right to
privacy assured.
I release the instructor from any liability for any injury or illness that I may suffer while undertaking the assessment, or
subsequently occurring in connection with the assessment or that is to any extent contributed to by it.
I hereby agree that I will present myself for testing in a suitable condition having abided by the requirements for diet
and activity advised for me.

Thanks for submitting!

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