Par q form


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 physician before they start becoming more physically active. Please complete this form as accurately and completely as possible.

Please mark YES or No to the following:

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? YesNo

Do you frequently have pains in your chest when you perform physical activity? YesNo

Have you had chest pain when you were not doing physical activity? YesNo

Have you had a stroke? YesNo

Do you lose your balance due to dizziness or do you ever lose consciousness? YesNo

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e., diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? YesNo

Are you pregnant now or have given birth within the last 6 months? YesNo

Do you have asthma or exercise induced asthma? YesNo

Do you have low blood sugar levels (hypoglycemia)? YesNo

Do you have diabetes? YesNo

Have you had a recent surgery? YesNo

Do you take any medications, either prescription or non-prescription, on a regular basis? YesNo

Please note: If your health changes such that you could then answer YES to any of the above questions, tell your trainer/coach. Ask whether you should change your physical activity plan.

I have read, understood, and completed the questionnaire. Any questions I had were answered to my full satisfaction.

1. I understand that Alborz Fitness sessions often take place outdoors, often on uneven ground and/or with limited lighting. I acknowledge and accept the potential dangers that my participation in sessions, in such conditions, may involve.
2. I confirm that I will inform the Trainer at the beginning of each session of any medical or other condition(s) that I may have that may affect my participation in that session. I acknowledge that whilst Alborz Fitness will take note of such condition(s) and advise of necessary alternatives to the session, I will proceed with the session at my own risk and am fully responsible for protecting my own health and safety in relation to any conditions I have. If I require medication such as an inhaler, it is my responsibility to bring these along to sessions. I agree to inform the Trainer of any conditions, and where necessary, provide written consent from my medical practitioner, before continuing with physical activity.
3. I agree to abide by all oral notices regarding safety and technique given during an Alborz Fitness session. I am aware that I have the opportunity to ask questions about the activities, use of equipment and other related issues during a session. If I choose to disregard any advice given, I do so at my own risk and accept liability for all resulting injuries or damage.
4. I understand that Alborz Fitness is not responsible or liable for any injuries or damage resulting from my participation in the session unless where Alborz Fitness has been negligent or failed to take reasonable care.
5. Those with medical conditions only: I can confirm that I have had approval from my GP to commence suitable exercise. Whilst I am aware that every effort has been taken to ensure that Alborz Fitness exercise classes are suitable for those with medical conditions, I understand that my participation and safety is my responsibility.