1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?(Required)

Yes

2. Do you feel pain in your chest when you do physical activity?(Required)

Yes

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

Yes

4. Do you lose your balance because of dizziness or do you ever lose consciousness?(Required)

Yes

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?(Required)

Yes

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

Yes

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

Yes

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 activities to those that are safe for you. Talk with your doctor about the kinds of activities 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 honestly to all PAR-Q questions, you can be reasonably sure that you can

✓ Start becoming much more physically 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 a fever—wait until you feel better; or
✓ If you are or may be pregnant—talk to your doctor before you start becoming more active.

Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

Informed Use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity.

No changes permitted. You are encouraged to copy 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 participates in a physical activity program or a fitness appraisal, this section may be used for legal or administrative purposes.

Name(Required)

Age(Required)

Email(Required)

Number(Required)

Date of birth(Required)

Emergency Contact

Witness

Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.

ACCESS LIABILITY AGREEMENT

To exercise/train at Shape Club Ltd during our OPEN GYM/PT/CLASS hours you must confirm you agree to the following:
✓ I hereby indemnify Shape Club Limited from and against any liability, loss, damage, and costs sustained by myself, the customer, whilst exercising at the club.

✓ I hereby indemnify Shape Club Limited from and against any injuries sustained by myself, the customer, whilst exercising in the club. I understand any exercising is at my own risk.

✓ I hereby confirm that no claim will be made from or against Shape Club Limited and/or its employees by myself, the customer.

I agree to indemnify Shape Club Limited from and against all liability and claims arising in respect of any injury, death, sickness, or ill health caused to or suffered by myself, the customer, whilst on the premises of/or when exercising at Shape Club Limited. I hereby confirm entering the PT Studio, attendance and partaking in any exercise is at my own risk during open hours and also understand that there will not always be a member of staff present.

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Date(Required)

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