Rebellion Fitness Medical Health Questionnaire

Full name*

First NameLast Name

Birth Date*

MonthDayYear

Age

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

Emergency contact*

First NameLast Name

Phone number*

Area CodePhone Number

Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Has any of your immediate family developed heart disease before the age of 60?
Do you feel fain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you suffer with lower back pain?
Do you have asthma?
Do you have epilepsy?
Are you pregnant or given birth/miscarried in the last 6 weeks?
Do you know of any other reason why you should not do physical activity?

Do you have or are you at risk of developing Diabetes?

If you're on any medications, please list them and state what they're for

If you have any current or previous injuries, please list them

How much alcohol do you drink per week?

Are you a current smoker? How much do you smoke per day?

I am aware of the risks in observing or participating in the activities offered and sponsored by Rebellion Fitness and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realise that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death. It is understood that Rebellion Fitness is responsible for any damage that would be resulting from a fault of Rebellion Fitness and its representatives.

Signature*

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Date*

DayMonthYear

Signature of Parent/Guardian if under 18*

Clear

Name

First NameLast Name

Relationship to client

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Medical Health Questionnaire

Health questionnaire (Par-Q)

Client information - Signature