Form

Physical Activity Readiness Questionnaire (PARQ Form)
Regular exercise is fun and healthy, and for most people it is safe. However, some people should check with their doctor before they start a new exercise program or become more physically active.

If you answer 'Yes' to any of the questions below, it's a good indication that you should check with your doctor before you start a new exercise program, and a written medical clearance may be necessary.

If you honestly answer 'No' to all of the questions below, it's a good indication that you can safely participate in a program by Fitness by M.

PLEASE NOTE: This physical activity clearance is valid at the time of signing, and if at any time your condition changes so that you would answer 'Yes' to any of the below questions, it is no longer valid and you must inform Fitness by M in writing and seek medical clearance before continuing participation.
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Do you have or have you ever had, a heart condition, high blood pressure, or circulatory problem?

Yes No
Is there a history of heart disease in your family?

Yes No
Do you ever experience pain in your chest when exercising or at rest?

Yes No
Do you ever feel faint or suffer from dizzy spells?

Yes No
Do you experience back pain or do you have a bone or joint condition (such as arthritis) that could be exacerbated by physical activity?

Yes No
Do you have diabetes?

Yes No
Do you have asthma?

Yes No
Do you suffer from epilepsy?

Yes No
Have you had any surgery or medical procedure in the past year that may affect your physical activity?

Yes No
Are you taking any prescribed medications?

Yes No
Are you aware of any other condition or injury that may give reason to modify your exercise program?

Yes No
For women:

Are you currently pregnant? Have you been pregnant in the last 6 months?
If you answered 'Yes' to any of the above questions, or have any additional information concerning your ability to participate in exercise, please provide details below:
Waiver Statement

To the best of my knowledge, understanding and belief, the information I have provided above is true and correct and I have no physical restriction to prohibit my participation in the program offered to me by Fitness by M.

I understand that I am participating in the exercise program from Fitness by M under my own free will, am responsible for monitoring my own physical conditions throughout the exercise program, and should any unusual symptoms occur, I will cease my participation and seek medical advice immediately.

In siginging this consent form, I acknowledge that I have read this waiver of liability and fully understand its terms. I agree to accept the risk of such exercise and further agree to not hold Fitness by M or the instructor/coach/person offering my fitness program liable for any and all claims, suits, losses or related cause of action for personal injuries or damages that may arise from my participation.
Signature:

Clear
Date

Month Day Year
Date
Should be Empty:

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Physical Activity Readiness Questionnaire (PARQ Form)