Date Your Contact Email Full Name Address Home Phone Cell Number Work Number Birthdate Sex
Male Female Present Weight Height Enter your Physicians name and contact number Enter your Emergency contact name and number Disclaimer: I understand that participating in any
program of exercise, nutrition and lifestyle change has certain risks. I realize that the information I provide is to determine
my potential risk category and to provide a subsequent exercise and nutrition program. The information I have supplied is
correct to the best of my knowledge. I also acknowledge that all participants in any program should consult their physician
before embarking on such a program. I take full responsibility for my participation in any of these programs for any claims
for injuries or illness that may result from my participation in any of their programs. Please type Signature. Signature Date Physical Activity Readiness Questionnaire - Par-Q (revised
1994). Par - Q - & You: (a questionnaire for people aged 15-69) Regular physical activity is fun and healthy and increasingly
more people are starting to become more active every day. Being more active is very safe for most people. However, some people
should check with their doctor before they start becoming much more physically active. Has your doctor ever said that you
have a heart condition and that you should only do physical activity recommended by a doctor?
Yes No Do you feel pain in your chest when you do physical
activity?
Yes No In the past month, have you had chest pain when you
were not doing physical activity?
Yes No Do you lose your balance because of dizziness or do
you ever lose consciousness?
Yes No Do you have a bone or joint problem that could be made
worse by a change in your physical activity?
Yes No Is your doctor currently prescribing drugs (for example,
water pills) for your blood pressure or heart condition?
Yes No Do you know of any other reason why you should not
be doing physical activity?
Yes No If you answered YES to one or more questions talk with
your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal.
Tell your doctor about this PAR-Q and which questions you answered YES. You may be able to do any activity you want - as
long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for
you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. Find out which
community programs are safe and helpful for you. If you answered NO to all questions, honestly then you can be reasonably
sure that you can: Start becoming much more physically active - being slowly and build up gradually. This is the safest and
easiest way to go. Take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you
can plan the best way for you to live actively. Delay becoming much more active if you are not feeling well because of a
temporary illness such as a cold or fever - wait until you feel better; or if you are or may be pregnant - talk to your doctor
before you start becoming more active. Please note: If your health changes so that you then answer YES to any of the above
questions, tell your fitness or health professional. Ask whether you should change your physical activity plan. (Informed
use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for persons
who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor prior to any activity.)
Note: If the PAR-Q is being given to a person before he or she participates in a physical activity program or fitness appraisal,
this section may be used for legal or administrative purposes. I have read, understood and completed this questionnaire.
Any questions I had were answered to my full satisfaction. Type Name: Signature (type name again) Date Please download a copy of this form for your records
as the back has information you need to retain. http://www.csep.ca/pdfs/par-q.pdf . Witness Signature (have someone Witness
this by typing their name in the space provided.) Diet & Exercise: How did you hear about my services? Are you currently exercising regularly?
Yes No If yes, how long have you been exercising regularly? Describe your cardiovascular exercise,
what you do, how long, at what intensity and how many times per week. Describe your resistance exercise, days
per week, hours per day, exercises, average sets, reps and weight used. Tell me about any extra activities you
do, what they are, how long, how many times per week (golf, soccer etc). What was your lightest weight after 21? What is your goal weight and or body fat? Describe any sports you competed in as
a kid, teen and at what level, approximately years and how long. Describe your daily average activity including
work and hobby, house chores etc. How many days per week are you willing to exercise
to achieve your goals? (This is not necessarily with a trainer, just in general, trainer or not)
2 3 4 5 6 At which intensity do you want to exercise?
light moderate vigorous Please list fully any injury or surgeries
and dates. How many meals per day do you consume? How many snacks per day? Describe your average breakfast. Describe your average lunch. Describe your average dinner. Describe your snacks. What are your food issues or foods you
will not eat, if you have any? (over eat, under eat, night eater, carb craver etc) Have you ever had or still have eating
disorders? If yes please explain with dates. Have you tried any diets or been on any
weight loss plans, if so please describe what and when, and your results. Do you drink or smoke, if yes please describe
how much and how often. Please describe all your goals (examples
are fat loss, muscle gains, injury rehab, sport or contest, wedding) and if you have a due date for your goal please indicate
this as well. Also any other info you wish to include regarding diet and exercise. Health: History of heart
problems, recurring chest pain, heart murmur, or stroke. Yes No Diagnosis of Hypertension
or take medicine for the same? Yes No Diabetes Mellitus Yes No Asthma, breathing or lung
problems Yes No Cancer (other than skin) Yes No Seizures, seizure medication,
neurological problems or severe dizziness Yes No Gallbladder disease or intestinal
problems Yes No Back problem, joint or muscle
disorder still affecting you Yes No Recent surgery (last 12 months) Yes No Hernia or any condition that
may be aggravated by lifting weights Yes No Physician's advice not
to exercise Yes No Are you pregnant, lactating
or anticipating becoming pregnant? Yes No If yes to any HEALTH question above, give
a brief explanation. History of total Cholesterol
greater than 240 mg/dl Yes No Family history of coronary
heart disease or other atherosclerotic disease in parents or siblings before age 55 Yes No Do you take vitamins or supplements? If
yes please explain. Do you have any food allergies at all
(soy, nuts, meats etc)? If yes please list. Please list any medications you may be
on as well and any other information you feel should be added. Informed Consent Agreement: I (enter your name) declare that I intend to use some of all of the activities,
facilities, programs and services offered by Body Rush and I understand that each person, myself included, has a different
capacity for participating in such activities, facilities, programs and services. I am aware that all activities, facilities,
programs and services offered are either educational, recreational or self - directed in nature. I assume full responsibility
during and after my participation for my choices to use or apply, at my own risk, any portion of the information or instruction
I receive. I understand that part of the risk involved in undertaking any activity or program is relative to my own state
of fitness or health (physical, mental, or emotional) and the awareness, care and skill with which I conduct myself in that
activity or program. I acknowledge that my choice to participate in any activity, service and program of BODY RUSH bring with
t the assumption by me of those risks or results stemming from this/these choice(s) and the fitness, health, awareness, care
and skill that I possess and use. In addition, I understand that I am free to withdraw from, reduce or modify my involvement
in any program activity and I realize that I should do so upon recognition of any signs of transient lightheadedness, fainting,
chest discomfort, leg cramps, nausea, etc. I further understand that the activities, programs and services offered by BODY
RUSH are sometimes conducted by personnel who may not be licensed, certified or registered instructors or professionals. I
accept the fact that the skills and competencies of some employees and/or volunteers will vary according to their training
and experience and that no claim is made to offer assessment or treatment of any mental or physical disease or condition by
those who are not duly licensed, certified or registered and herein employed to provide such professional services. I acknowledge
that I have inquired about the nature of any activity, program or services that I am not completely familiar with and I have
been informed of any inherent risks. I further understand that BODY RUSH would not permit me to participate in any activity,
facility, program and/or service unless I signed this Informed Consent Agreement, that this Informed Consent Agreement applies
to all the activities, facilities, programs and/or services in which I participate whether occurring in the near or distant
future and that the terms of this Informed Consent Agreement need not be brought to my attention each time I participate in
any activities, facilities, programs and/or services in order to be effective. I understand clearly that by signing this
Informed Consent Agreement I will be forever prevented from suing or otherwise claiming against BODY RUSH, its officers directors,
employees, independent contractors and agents, for any loss or damage connection with any property loss or personal injury
that I may sustain while participating in or preparing for any program and/or activity whether or not such loss or injury
is caused solely or partly by the NEGLIGENCE of BODY RUSH or any of its officers, directors, employees, independent contractor
and agents. I declare that I have read, understood and agree to the contents of this Informed Consent Agreement in its entirety.
Participant Signature: Date for Informed Consent Witness and Date
