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YOUTH Fitness Data Sheet

Gender Identity

 

In case of emergency, please contact:

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?
When you perform physical activity, do you feel pain in your chest?
Do you ever faint or get dizzy and lose your balance, or consciousness?
Do you have a bone or joint problem that could be aggravated by physical activity?
Do you have high blood pressure or a heart condition for which a physician is currently prescribing a medication?
Are you pregnant or have you given birth within the last 6 months?
Do you have insulin dependent diabetes, or do you have hypoglycemia?
Do you suffer from exercise-induced asthma?
Are you 65 years of age or older and not used to being very active?
Have you had a recent surgery, and/or are you on any medication?
Have you had a stroke?
Are you aware, through your own experience or a doctor’s advice, of any other physical reason against your exercising without medical supervision?
Have you consulted your physician regarding increasing your physical activity and/or performing a fitness assessment?
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?

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

Have you ever had (or currently have) any of the following? (please check all that apply)
Are you currently taking any medication (depression/High BP)?

Family History

Please check any statements that apply to your family history.

Personal Pulmonary Hygiene

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

Muscular/Bone/Joint History

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

Other Medical Problems

Have you ever had (or currently have) any of the following (please check all that apply)?
Have you had surgery or been in a hospital for medical treatment?
Are you under any type of medical observation or receiving treatment?

INFORMED CONSENT AND CANCELLATION POLICY

I hereby voluntarily give consent for my minor child 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 and my child are responsible for monitoring my child's condition when exercising, and should any unusual symptoms occur, my child will cease 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 my child being allowed to participate in the fitness tests, I, on behalf of my minor child, 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 minor child's 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 about my minor child, are true and correct.