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The Physical Activity Readiness Questionnaire (PARQ) enables your personal trainer to understand any health limitations you may have before beginning a training program.  This form is HIPAA-compliant - it is not sent via email and is encrypted/password protected on our end.

Please answer the following questions as honestly as you can.  You can provide any additional relevant information to your trainer in person, if you prefer.  Scroll below the signature to find the questions at the bottom.  Then scroll up to sign.

I Agree
I have answered all questions in this form honestly and I am aware that if I have answered yes to any of the questions I will need to consult my doctor before commencing an exercise program if I am affected by any of the questions mentioned in this form.  This form is valid for 12 months and becomes invalid if my medical history changes.  I agree to inform my personal trainer of any changes.

June 13, 2021

First Client Name

First Name*

Last Name*
First Client Date of Birth*
First Client Signature*
Second Client Name

First Name*

Last Name*
Second Client Date of Birth*
Third Client Name

First Name*

Last Name*
Third Client Date of Birth*
Fourth Client Name

First Name*

Last Name*
Fourth Client Date of Birth*
Fifth Client Name

First Name*

Last Name*
Fifth Client Date of Birth*
Sixth Client Name

First Name*

Last Name*
Sixth Client Date of Birth*
Seventh Client Name

First Name*

Last Name*
Seventh Client Date of Birth*
Eighth Client Name

First Name*

Last Name*
Eighth Client Date of Birth*
Ninth Client Name

First Name*

Last Name*
Ninth Client Date of Birth*
Tenth Client Name

First Name*

Last Name*
Tenth Client Date of Birth*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Please read carefully and answer these questions:
Has your doctor ever said that you have any of the following OR that you should only perform physical activity recommended by a doctor? *
A heart condition
High Blood Pressure
Asthma or a breathing problem
Diabetes
Do you feel pain in your chest at rest, during daily activities, or when you do physical activities?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?*
No
Yes
Do you have a bone or joint problem that could be made worse by a change in your physical activity? (ex: osteoporosis, pins/plates, or arthritis?)*
No
Yes
Is your doctor currently prescribing any medication for your blood pressure or a heart condition?*
No
Yes

Do you know of any other reason why you should not engage in physical activity? (if no, please skip)
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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