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PARQ
Gym & Fitness Liability Waiver
First name
Last name
Email
Date of Birth
Has a doctor ever said that you have bone or joint problems such as arthritis, that has been aggravated by exercise or made worse with exercise?
No
Yes
Do you have Diabetes Mellitus or any other metabolic disease?
No
Yes
Has your doctor ever said that you have raised cholestrol (above 6.2mmol/l)?
No
Yes
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by your doctor?
No
Yes
Have you ever felt pain in your chest when you do physical activity?
No
Yes
Is your doctor currently prescribing you any drugs or medication?
No
Yes
Have you ever suffered from shortness of breath at rest or with mild exertion?
No
Yes
Is there a history of heart problems in your family?
No
Yes
Do you often feel faint, have spells or severe dizziness or have lost consciousness?
No
Yes
Do you currently drink more than the average amount of alcohol each week (21 units for men and 14 units for women)?
No
Yes
Do you currently smoke?
No
Yes
Do you NOT currently exercise on a regular basis (at least 3 times per week)?
No
Yes
Are you, or is there a possbility that you might be pregnant?
No
Yes
Do you know of any other reason why you should not participate in a programme of physical activity?
No
Yes
If YES to any of the above please provide more information:
Home address and Emergency Contact:
Initial to sign:
I declare that the info I’ve provided is accurate & complete
I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.
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Thanks for submitting!
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