RevUp/Reload Paperwork

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name and Phone Number*

Date of Birth (MM/DD/YY)*

What type of membership do you have with LSPR?*

AnnualFlexNo membership

How would you rank your overall physical fitness level?*

PoorFairGoodExcellent

How many days per week do you engage in aerobic exercise for at least 30-60 minutes in duration? (Examples: fitness walking, cycling, active sports, etc.)*

Never1-2 days a week3-5 days a week6-7 days a week

How many times per week do you engage in strength training sessions? (Examples: back squats, deadlifts, or bench press)*

Never1-2 days a week3-5 days a week6-7 days a week

How often do you exercise at a fitness center or gym?*

Less than once a month1-4 times a month2-3 times a week3-6 times a week

How would you rate your overall health?*

PoorFairGoodExcellent

How would you rank your overall nutrition or diet?*

PoorFairGoodExcellent

List 3 specific goals you wish to accomplish through RevUp.

Have you had a heart attack, stroke, or heart surgery?*

YesNo

If you answered YES, please specify. If NO, enter N/A.

Has your doctor said you have cardiovascular, pulmonary, metabolic or other significant disease?*

YesNo

Has your doctor said that you have a heart murmur or irregular heart beat?*

YesNo

During or right after exercise, do you have pains or pressure in the left or mid-chest area, left neck, shoulder or arms?*

YesNo

Do you experience shortness of breath at rest or with mild exertion?*

YesNo

Do you experience dizziness/fainting spells at rest or with exertion?*

YesNo

Do you have insulin-dependent diabetes or take medication to control your blood sugar?*

YesNo

Have you experienced leg pain upon exertion?*

YesNo

Has your doctor said that you have a musculoskeletal disorder that could be made worse by physical activity (i.e., bursitis, arthritis, joint or muscle disorder, etc.)?*

YesNo

If YES, please specify. If NO, enter N/A.

Are you currently taking prescription medication for an underlying disorder (i.e., heart, lung, GI, blood) that may impact your ability to exercise? If yes, please let the staff know.*

YesNo

Are you currently pregnant or within six weeks postpartum?*

YesNo

Do you have a medical condition not mentioned here which might affect your ability to participate in an exercise program (i.e., seizures, emphysema, asthma, etc.)?*

YesNo

If YES, please specify. If NO, enter N/A.

If you answered YES to any of the statements above, you must consult your physician before engaging in exercise. Enter N/A if you answered no to all questions. List any other health issues that may hinder exercise performance:

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

YesNo

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

YesNo

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

YesNo

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

YesNo

Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

YesNo

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

YesNo

Is your doctor currently prescribing drugs for your blood pressure or heart condition?*

YesNo

If you answered: YES to one or more questions

Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.
You may be able to do any activity you want - as long as you start slowly and build up gradually. Or, you may need to restrict your actvities to those which are safe for you.
Talk with you doctor about the kind of activites you wish to participate in and follow his/her advice.
Find out which community programs are safe and helpful for you.

If you answered: NO to all questions

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:
- Start becoming much more physcially active - begin slowly and build up gradually. This is the safest and easiest way to go.
- Take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively.
- It is also highly recommended that you have your blood pressure evaluated.
- If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.

DELAY BECOMING MUCH MORE ACTIVE:

If you are not feeling well because of a temporary illness such as a cold or fever - wait until you feel better.
If you are or may be pregnant - talk to your doctor before you start becoming more active.
No changes permitted. You are encouraged to photocopy the PAR-Q but only if you use the entire form.
NOTE: If the PAR-Q is being given to a person before he or she particpates in a physical activity program or fitness appraisal, this section may be used for legal or administrative purposes.

RevUp includes 6 small group sessions with a personal trainer over a 6 week period.
RevUp is small group training and consists of 4 to 7 participants in each group.
The 6 small group sessions must be completed within the 6 week period.
Any sessions not completed in the 6 week period will not be made up after the 6 week time period unless paid and enrolled in the next RevUp Reload.
All payments must be made in full upon enrollment.

Signature*

RevUp Reload Paperwork

Health Status Questionnaire

Par-Q & You

RevUp 6 Week Service Agreement: