Physical Activity Readiness Questionnaire

Date:	_____________________________
Name:	_____________________________
Address:	_____________________________
City:	_____________________________
State:	_____________________________
Phone:	_____________________________
Email:	_____________________________
Gender:	_____________________________
Birth Date	_____________________________
Emergency Contact & Phone:	_____________________________

 

 

 

 

 

 

 

 

 

Regular exercise is beneficial to your health in general, however one must be careful about any associated injury risk. Please fill in the form below carefully so that your training program can be properly planned in accordance with your risk profile.

Please answer Yes or No to the following questions:

1. Do you have a heart condition due to which you should only undertake physical activity recommended by a physician?

2. When you do physical activity do you feel pain in your chest?

3. When you are not doing physical activity, have you had chest pain in the past month?

4. Do you ever lose consciousness or lose your balance due to dizziness?

5. Do you have a joint or bone problem that may get worse due to physical activity?

6. Is a doctor currently prescribing medication for your blood pressure or heart condition?

7. Are you pregnant or post-partum?

8. Do you have insulin dependent diabetes?

9. Do you know of any other reason you should not exercise or increase your physical activity?

10. Are you a man over the age of 45 or a woman over the age of 55?

If you answer ‘Yes’ to any one question, please get a medical authorization a doctor to undertake training.

If you answered ‘No’ honestly to all questions, you can be reasonably sure that you are fit to undertake the training program.

Note: if you have changes so that you then answer yes to any of the above questions, please tell your personal trainer immediately and ask him/her if any change in your training is required.

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction. I understand that I will be going through a strenuous physical training routine during which I could get injured. I am voluntarily participating in this training program and take full responsibility of any risks due to injury that might result. I agree to waive any claim or right to sue Bob Thomson, Tymor Park, the Town of Union Vale or any agent, employees, instructors or anybody else associated with the training program for injury to myself as a result of the training activity.

Participant's Signature _____________________________      Date _____________

Witness Name & Signature _____________________________    Date _____________