PAR-Q

PAR-Q (A Physical Activity Readiness 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. If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO.

1. 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

Please explain:

2. Do you feel pain in your chest when you do physical activity? *

Yes
No

Please explain:

3. In the past month, have you had chest pain when you were not doing physical activity? *

Yes
No

Please explain:

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

Yes
No

Please explain:

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

Yes
No

Please explain:

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes
No

Please explain:

7. Do you know of any other reason why you should not do physical activity? *

Yes
No

Please explain:

8. Do you have any current or pre-existing injuries that may affect your ability to exercise? *

Yes
No

Please explain:

Name *

First

Last

Date *

Date of Birth *

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Are you 18 years of age or older? *

Yes
No

Signature *

Clear Signature

Name of Parent/Guardian *

First

Last

Signature of Parent/Guardian *

Clear Signature

Witness *

Clear Signature

Terms of Service *

I have read and agree to the Terms of Service *

Please read these Terms of Service ("Terms", "Terms of Service") carefully before using the program (the "Service" operated by Dan North Fitness Inc.).

Your access to and use of the Service is conditioned on your acceptance of and compliance with these Terms.

Exercise Waiver

I hereby agree to participate in the exercise program given by Dan North Fitness Inc. (hereafter referred to as “The Company”) upon the understanding and condition that:

1. I acknowledge that The Company has advised me of medical risks that may result from such participation and represent to The Company that I have consulted my personal physician if I have been advised to do so by the PAR-Q and I am physically capable of such participation without injury.

2. I am aware of the medical risks associated with participating in an intense exercise program, including the possibility of injuries resulting from the activities performed such as jumping, weight lifting, and all other physical activities associated with the exercise program.

3. I recognize the risks of illness or injury inherent in a group exercise program and am participating in The Company’s program upon the express agreement and understanding that I am hereby waiving and releasing The Company from any and all claims, costs, liability, expenses or judgments including attorney’s fees and court cost (herein, collectively “Claims”) arising out of my participation in The Company’s programs or any illness or injury resulting there from, and hereby agree to indemnify and hold harmless The Company from and against any and all such Claims.

4. I hereby execute and deliver this waiver and release to induce The Company to permit me to participate in its program.

PAR-Q (A Physical Activity Readiness Questionnaire for People Aged 15-69)

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