Par-Q Form – Body Fitness League

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1-677-124-44227

info@yourbusiness.com

184 MAIN COLLINS STREET WEST VICTORIA 8007

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Your Medical History

Please complete the questions below. All information given is kept strictly confidential.

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Full-Name *

Date of Birth//

Phone Number *

Email *

1. Do you have, or have you ever had, a heart condition, high blood pressure or circulatory problems? *

2. Is there a history of heart disease in your family? *

3. Do you ever experience pain in your chest when exercising or at rest? *

4. Do you ever feel faint or suffer from dizzy spells? *

5. Do you have a bone or joint condition (such as arthritis) that could be exacerbated by physical activity? *

6. Do you have diabetes? *

7. Do you have asthma? *

8. Do you suffer from epilepsy? *

9. Have you had any surgery or medical procedure in the past year that may affect your physical activity? *

10. Are you currently taking any prescribed medications? *

11. Do you suffer from back pain? *

12. Are you aware of any other condition or injury that may give reason to modify your exercise programme e.g. pregnancy/high cholesterol? *

Please provide additional details if necessary: *

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Client's Signature *

Dated *

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Body Fitness League

Want to achieve fitness goals but don't know how to? Give us your undivided attention to get results in the shortest time frame possible through sensible eating and being more active.

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CONTACT

E-mail: info@fitnessjustice.com

+44 7885 899 639

Book A Class

Full Name *

Contact Number *

Class Name *

Location *

Date / Time *

Date

Time