PARQ and Disclaimer

Full Name

Full Address

Contact Number

Email Address

Date Of Birth

Emergency Contact - Full Name

Emergency Contact Number

Emergency Contact Relationship

Question 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by your doctor?

YES NO

Question 2. Have you ever felt pain in your chest when you do physical exercise?

YES NO

Question 3. In the past month, have you had a chest pain when you were not doing any physical exercise?

YES NO

Question 4. Do you lose balance because of dizziness or do you ever lose consciousness?

YES NO

Question 5. Have you ever suffered from unusual shortness of breath at rest or with mild exertion? Or suffer from asthma?

YES NO

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

YES NO

Question 7. Do you have Diabetes Mellitus or any other metabolic disease?

YES NO

Question 8. Are you, or have you been pregnant in the past 6 months?

YES NO

Question 9. Have you been recently hospitalised?

YES NO

Question 10. Are you currently on any prescribed medicines that may affect your ability to exercise?

YES NO

Question 11. Do you have a joint or bone problem (for example back, knee, hip) that could be made worse by a change in your physical activity?

YES NO

Question 12. Do you know of any other reason why you should not participate in a programme of physical activity?

YES NO

If you answered 'YES' to one or more questions, please write full details here (or N/A if not applicable).

If you answered 'YES' to one or more of the questions above, you agree to consult with your doctor before becoming physically active.
This PARQ becomes invalid if your condition changes so that you would answer YES to any of the questions.

I Agree

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise and my participation involves a risk of injury.

I Confirm

GENERAL STATEMENT OF PROGRAMME OBJECTIVES AND PROCEDURES:

I understand that this personal training programme may include exercises to build the cardio respiratory system (heart and lungs), the musculoskeletal system, (which involves muscular endurance, strength and overall flexibility), and to improve body composition (increasing muscle and bone and decreasing body fat).

Exercise includes aerobic activities, such as walking, running, cycling, rowing machine and other aerobic activities, weight lifting using dumbbells, machines and other equipment to improve muscular strength and endurance, as well as flexibility exercises to improve joint range of motion.

DESCRIPTION OF POTENTIAL RISKS:

I understand that no exercise programme is without inherent risks regardless of the care taken by a coach and that my personal safety cannot be guaranteed by my coach. I realise that when participating in any exercises, particularly those that induce cardiovascular stress, there is a slight chance of serious injury (e.g. heart attack, stroke, or other cardiovascular accidents) or catastrophic incident (e.g. death, paralysis).

Likewise, I know that engaging in muscular endurance, strength building, and other fitness activities sometimes results in minor injuries (e.g. bruises, musculoskeletal strains and sprains), less frequent, more serious injuries (e.g. muscle tears, herniated disks, torn rotator cuffs), and rarely, catastrophic injury (e.g. death, paralysis).

DESCRIPTION OF POTENTIAL BENEFITS:

I understand that a regular exercise programme has been shown to have definite benefits to general health and well-being. I know that some of the benefits can include loss of weight, reduction of body fat, improvement of blood lipids, lowering of blood pressure, improvement of cardiovascular function, reduction in the risk of heart disease, improved strength and muscular endurance, improved posture, and improved flexibility.

PARTICIPANT RESPONSIBILITIES:

I understand that it is my responsibility to fully disclose any health issues or medications that are relevant to participation in a strenuous exercise program. Inform the coach and cease exercise and report promptly any unusual feelings (e.g. chest discomfort, nausea, difficulty breathing, apparent injury).

AKNOWLEDGMENT OF RISKS:

I acknowledge that physical exercise can involve a risk of serious injury or even death. I understand that it is my responsibility to consult a doctor prior to my participation in this exercise program, if I feel it is necessary. I declare that I am physically fit and able to participate in this programme.

RELEASE OF LIABILITY:

I hereby release Ultimate Health & Fitness/Chris Melhuish PT, it's trainers, employees, agents and representatives from any claims, demands and causes of action arising from my participation in the exercise programme.

I fully understand that I may injure myself as a result of my participation and I voluntarily assume the risk of such injury. I agree to indemnify and hold harmless Ultimate Health & Fitness/Chris Melhuish PT, against any claims of injury, damage or loss.

ACKNOWLEDGEMENT OF UNDERSTANDING:

I have read this waiver and release of liability and fully understand its terms.

I acknowledge that I am signing this waiver freely and voluntarily.

I agree that this waiver and release is binding upon myself, my heirs, executors, administrators and representatives.

By accepting and signing this release below, I acknowledge that I understand its content and that this release cannot be modified.

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TODAYS DATE

GENERAL STATEMENT OF PROGRAMME OBJECTIVES AND PROCEDURES:

DESCRIPTION OF POTENTIAL RISKS:

DESCRIPTION OF POTENTIAL BENEFITS:

PARTICIPANT RESPONSIBILITIES:

AKNOWLEDGMENT OF RISKS:

RELEASE OF LIABILITY:

ACKNOWLEDGEMENT OF UNDERSTANDING: