Loading...

The Physical Activity Readiness Questionnaire for Everyone

The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.


Today's Date: October 26, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Has your doctor ever said that you have a heart condition OR high blood pressure?*
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?*
No
Yes
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
No
Yes

PLEASE LIST CONDITION(S) HERE:
Are you currently taking prescribed medications for a chronic medical condition?*
No
Yes

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *
No
Yes
Has your doctor ever said that you should only do medically supervised physical activity?*
No
Yes

If you answered NO to all of the questions above, you are cleared for physical activity.

Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active – start slowly and build up gradually.

You may take part in a health and fitness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. 

Do you have Arthritis, Osteoporosis, or Back Problems?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?*
No
Yes
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?*
No
Yes
Do you currently have Cancer of any kind?*
No
Yes
Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?*
No
Yes
Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?*
No
Yes
Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have an irregular heart beat that requires medical management? (e.g., atrial "brillation, premature ventricular contraction)*
No
Yes
Do you have chronic heart failure?*
No
Yes
Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?*
No
Yes
Do you currently have High Blood Pressure?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)*
No
Yes
Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes*
No
Yes
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?*
No
Yes
Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty peaking, weakness, or sleepiness.*
No
Yes
Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?*
No
Yes
Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?*
No
Yes
Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?*
No
Yes
Do you have any Mental Health Problems or Learning Di!culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have Down Syndrome AND back problems affecting nerves or muscles?*
No
Yes
Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure*
No
Yes
Do you have di!culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?*
No
Yes
If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?*
No
Yes
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?*
No
Yes
Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you commonly exhibit low resting blood pressure signi"cant enough to cause dizziness, light-headedness, and/or fainting?*
No
Yes
Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?*
No
Yes
Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)*
No
Yes
Do you have any impairment in walking or mobility?*
No
Yes
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?*
No
Yes
Do you have any other medical condition not listed above or do you have two or more medical conditions?*
No
Yes
Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?*
No
Yes
Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?*
No
Yes
Do you currently live with two or more medical conditions?*
No
Yes

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fittness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition:

You should seek further information before becoming more physically active or engaging in a "fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a qualified exercise professional to help you develop a safe and elective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal

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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!