PAR-Q CPR Health and Fitness

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Do you have diabetes or any other metabolic disorder? *

Yes

No

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

Yes

No

Do you have a bone or joint problem that could be made worse by physical activity *

Yes

No

Is your doctor currently prescribing medication for your blood pressure, a heart condition or any other condition? *

Yes

No

Has your doctor ever said you have raised cholesterol? *

Yes

No

Are you currently or have you recently been pregnant? *

Yes

No

Are you a smoker? *

Yes

No

Are you asthmatic? *

Yes

No

How would you evaluate your current level of stress? *

High

Moderate

Low

How would you evaluate your mood? *

Stable

Up & Down

Consistently bad

Do you leak (urinary or fecal) when you laugh, run, cough, sneeze or jump (AT ALL)? *

Yes

No

Do you have pelvic organ prolapse (POP)? Any feeling of heaviness or bulging in your pelvis? *

Yes

No

Have you had any surgical operations in the last 10 years? This includes c-sections? *

Yes

No

Please Identify if you would like help with any of the following

Fat loss

Help to improve digestion

High Cholesterol

High Blood Pressure

Control of a medical condition such as Type 2 Diabetes

Improved relationship with food

Any other personalised nutritional advice

Assumption of risk - I hereby agree that I have read, understood and answered honestly the questions above. I also state that I wish to participate in a gradual exercise program. I realise that my participation in these activities involve the risk of injury and even the possibility of death. I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me *

I agree

Date *

MM

DD

YYYY

The data collected on this form is done so in line with our privacy policy notice for members. Please ensure you have read and understood our privacy policy in full before signing this form. The privacy notice sets out the legal basis for processing this data, how long we will keep this data for, how we protect your personal information and your rights in relation to the personal data that we hold on you. A copy of the policy can be found on our website www.cprhealthandfitness.com *

I have read the above statement