PARQ YOUR DETAILS 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. Has your Doctor ever said you should NOT take part in physical activity? YesNo Has your Doctor ever said that you have a heart condition? YesNo Has your Doctor ever said that you have high/low blood pressure? YesNo Are you taking any medication for your blood pressure or heart condition? YesNo Do you have Diabetes Mellitus or any other form of Diabetes? YesNo Do you, or have you recently felt pain in your chest when doing physical activity? YesNo Do you ever lose balance, become dizzy or ever lose consciousness? YesNo Do you have any injuries that could be aggravated by exercise? YesNo More specifically, do you have any joint problems including back, knees and/or neck? YesNo Has anyone in your immediate family had a heart attack prior to the age of 55 years? YesNo Has your Doctor ever said you have raised cholesterol levels? YesNo Have you ever been short of breath, had difficulty breathing or been diagnosed with asthma? YesNo Do you suffer from Epilepsy? YesNo Are you or do you think you may be, pregnant? YesNo 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 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 during a training session, my trainer may have to use Touch Training to correct alignment and/or to focus my concentration on a particular muscle area to be targeted. If I feel uncomfortable or experience any type of discomfort with Touch Training, I will immediately request that my trainer discontinue using this technique. I understand that Reach Fitness may photograph and/or film their client events/sessions and I agree to allow them to use these pictures, films, and/or likenesses of me for 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 of this in writing. I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. 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 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
