ADULT Fitness Data Sheet - Levine Jewish Community Center, Charlotte, NC

Program

Last Name

First Name

Middle Name

Age

Date of birth

Address

City

State

Zip

Contact Number (best)

Type

Contact Number (alternative)

Type

Gender Identity

In case of emergency, please contact:

Name

Relationship

Address

Phone

Physical Activity Readiness Questionnaire (PAR-Q)

Regular exercise is associated with many health benefits. Increasing physical activity is safe for most people. However, some individuals should check with their physician before they become more physically active. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life. Please read each question carefully and answer every question honestly.

Has a physician ever diagnosed you with a heart condition and recommended only medically supervised physical activity?

Yes No

When you perform physical activity, do you feel pain in your chest?

Yes No

Do you ever faint or get dizzy and lose your balance, or consciousness?

Yes No

Do you have a bone or joint problem that could be aggravated by physical activity?

Yes No

Do you have high blood pressure or a heart condition for which a physician is currently prescribing a medication?

Yes No

Are you pregnant or have you given birth within the last 6 months?

Yes No Not Applicable

Do you have insulin dependent diabetes, or do you have hypoglycemia?

Yes No

Do you suffer from exercise-induced asthma?

Yes No

Are you 65 years of age or older and not used to being very active?

Yes No

Have you had a recent surgery, and/or are you on any medication?

Yes No

Have you had a stroke?

Yes No

Are you aware, through your own experience or a doctor’s advice, of any other physical reason against your exercising without medical supervision?

Yes No

Have you consulted your physician regarding increasing your physical activity and/or performing a fitness assessment?

Yes No

If you answered NO to the previous question, will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?

Yes No

If you answered yes to any of the above questions, talk with your doctor before you become more physically active. Tell your doctor your plan to exercise and to which questions you answered yes. If you honestly answered no to all questions you can be reasonably certain you can safely increase your level of physical activity gradually. If your health changes so you then answer yes to any of the above questions, seek guidance from a physician.

Personal Medical History

If yes, please explain

Are you currently taking any medication (depression/High BP)?

Yes No

If yes, please list and explain

Family History

Please check any statements that apply to your family history.

Parent died of heart attack prior to age 50 Sibling died of heart attack prior to age 50 Parents/siblings with high blood pressure Parents/siblings with stroke Parents/siblings with diabetes Other

If yes, please explain

Personal Pulmonary Hygiene

Have you ever had (or currently have) any of the following? (please check all that apply)

If yes, please explain

Muscular/Bone/Joint History

Have you ever had (or currently have) any of the following (please check all that apply)?

If yes, please explain

Other Medical Problems

If yes, please explain

Have you had surgery or been in a hospital for medical treatment?

Yes No

If yes, please explain

Are you under any type of medical observation or receiving treatment?

Yes No

If yes, please explain

Exercise Goals and Intent

If you selected "other," please explain.

In 6 months, how would you like to describe your body, physical vitality or performance?

Why is this outcome important to you?

How long have you been thinking about getting into better shape?

How do you envision your trainer facilitating your success?

What are your short term goals?

What are your long term goals?

How will you reward yourself for reaching your short term goals?

What will be your reward for reaching your long term goals?

INFORMED CONSENT AND CANCELLATION POLICY

I hereby voluntarily give consent to engage in physical fitness. I understand there are certain changes which may occur during exercise. They include abnormal blood pressure, fainting, disorders of heart beat, and very rare instances of heart attack. I understand that every effort will be made to minimize problems during exercise.

I understand that I am responsible for monitoring my condition when exercising, and should any unusual symptoms occur, I will cease my participation and inform the trainer of the symptoms. Unusual symptoms include, but are not limited to: chest discomfort, nausea, difficulty in breathing, and joint or muscle injury. Also, in consideration of being allowed to participate in the fitness tests, I agree to assume all risks of such exercise, and hereby release and hold harmless the Levine Jewish Community Center, and their agents and employees, from any and all health claims, suits, losses, or causes of action for damages, for injury or death, including claims for negligence, arising out of or related to my participation in physical fitness. I have read the foregoing carefully and I understand its content. Any questions which may have occurred to me concerning this informed consent have been answered to my satisfaction.

I understand there is a 24 hour cancellation policy for private, semi-private, and group sessions. If not cancelled within 24 hours, I will be subject to be charged for the missed session.

I attest that the answers provided on the foregoing Physical Activity Readiness Questionnaire, as well as all medical information are true and correct.

Name