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PLEASE LIST CONDITION(S) HERE:
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PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
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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. |
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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 |