Physical Activity Readiness Questionnaire (PAR-Q)

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I am so excited to begin working with you as your Personal Fitness Coach!

The following online form should take you less than 5 minutes to complete.

If you have any questions, just ask Michelle: info@bwmfitness.ca

Email *

PART 1: PERSONAL INFORMATION

Full Name *

Phone Number *

Date of Birth *

YYYY

PART 3: PAR-Q

This form acts as a PAR-Q (Physical Activity Readiness Questionnaire) that will help determine whether or not it's safe for you to begin a new exercise program. Please answer the following questions honestly, and provide as much detail as possible where applicable.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

Do you feel pain in your chest when you do physical activity? *

Yes

In the past month, have you had chest pain when you were not doing physical activity? *

Yes

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? If yes, please add as much detail as possible. *

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes

Do you know of any other reason why you should not do physical activity? *

Yes

If you answered YES to the previous question, please explain in detail here:

PART 5: WAIVER OF LIABILITY

It's important that you understand that any form of physical exercise can be strenuous and subject to risk of serious injury. You are urged to obtain a physical examination from a doctor before participating in any exercise activity, including those provided by Big White Mountain Fitness Ltd.

You agree that if you engage in any physical exercise or activity, you do so entirely at your own risk.

I, the applicant, on behalf of myself, members of my family, my heirs, executors, administrators and assigns, hereby forever release, discharge and hold harmless Big White Mountain Fitness Ltd and staff.

This waiver and release of liability includes, without limitation, all injuries which may occur as a result of: (a) your participation in any activity or participation in any exercise routine and (b) instruction, training, supervision, or dietary recommendations by Michelle Smith for Big White Mountain Fitness Ltd.

You acknowledge that you have carefully read this “waiver and release” and fully understand that it is a release of liability. You expressly agree to release and discharge Big White Mountain Fitness Ltd and staff from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against Big White Mountain Fitness Ltd, Michelle Smith and staff for personal injury or property damage. By signing this release, you acknowledge and understand its content and that this release cannot be modified orally.

I have read the above Waiver of Liability and agree to its terms: *

Yes

Required

PART 6: MUTUAL GOAL AGREEMENT

As your coach, my goal is to help you reach ALL of your health and wellness goals. Once I help you reach those goals, I ask that you help me reach my goal, which is to coach other clients like you to success!

Once you've reached your goals, would you connect me with people you know who could use my help?
Does this sound like a fair deal?

I have read the above Mutual Goal Agreement and think this is a fair deal: *

Yes

Do you give permission for any photos of you to be used on Social Media? *

Yes

Other:

PART 7: FINAL THOUGHTS & SIGNATURE

Is there anything else you'd like to share? If so, please do so here:

I agree that all information provided on this form is accurate to the best of my knowledge: *

I agree

Required

Type your full name here as your digital signature: *

Date: *

YYYY

A copy of your responses will be emailed to the address you provided.

Submit

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