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Physical Activity Readiness Questionnaire
Payment & Cancellation Agreement
Waiver
Physical Activity Readiness Questionnaire
All fields with a red asterisk must be completed. Click "submit" when finished.
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Indicates required field
Name
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First
Last
Birth Date: MM/DD/YY
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Street Address:
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City, State, Zip
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Mobile # xxx-xxx-xxxx
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Home # xxx-xxx-xxxx
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Email
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Has your doctor ever informed you that you have heart problems or a heart murmur?
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yes
no
Do you currently have high blood pressure?
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yes
no
Have you undergone any major surgeries in the last two years?
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yes
no
Do you have diabetes?
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type 1
type 2
no
Do you have any bone or joint problems that may become aggravated with exercise?
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yes
no
Are you currently taking medication?
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yes
no
Please list any medications you are taking:
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Do you have any concerns about participating in a strenuous fitness program such as dizziness, fainting, chest pains, pregnancy, low back pain, smoking, or any concerns not listed here?
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Is there anything not listed above, that I should be aware of in order to appropriately design a safe and effective fitness program for you?
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I intend to engage in strenuous physical activities. I acknowledge that these activities involve certain risks, including the possibility of death, and I understand that by participating in an exercise program that I voluntarily assume these risks. I mean to include in the assumption of risk, the risk of injury, no matter how serious.
I hereby release and forever discharge Ideal You Fitness, LLC, Jill Buchert, and/or John Buchert, all of their management, partners, agents, contractors, employees (whether acting within the scope of their employment or not), and heirs from any claims, demands, or causes of action relating to or arising from my presence or participation in an exercise program, which may result in injury to me or even death. I intend this release to bind my heirs, executors, assigns, administrators, personal representatives, agents acting on my behalf and myself. Your typed name below represents your legal, binding signature and your agreement to these terms, as well as your attesting that all information you have provided is true and correct to the best of your knowledge.
NAME:
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TODAY'S DATE:
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Submit
IDEAL YOU FITNESS; ALL RIGHTS RESERVED; 2011