|
Exercise Readiness Questionnaire
|
Name |
Date |
| DOB |
Age |
Home Phone |
Work Phone |
Regular exercise is associated with many health benefits. Increasing physical activity is safe for most people. However, some individuals should check with a 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:
| Yes |
No |
1) Has a physician ever diagnosed you with a heart condition and indicated you should restrict your physical activity? |
| Yes |
No |
2) When you perform physical activity, do you feel pain in your chest? |
| Yes |
No |
3) When you were not engaging in physical activity, have you experienced chest pain in the past month? |
| Yes |
No |
4) Do you ever faint or get dizzy and lose your balance? |
| Yes |
No |
5) Do you have an injury or orthopedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity? |
| Yes |
No |
6) Do you have high blood pressure or a heart condition in which a physician is currently prescribing a medication? |
| Yes |
No |
7) Are you pregnant? |
| Yes |
No |
8) Do you have insulin dependent diabetes? |
| Yes |
No |
9) Are you 69 years of age or older and not used to being very active? |
| Yes |
No |
10) Do you know of any other reason you should not exercise or increase your physical activity? |
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 answer 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.
| Participant signature |
Date |
_________________________________________________________________________________
Release of Liability
1. In consideration of being allowed to participate in the activities and training programs of Peak Performance Conditioning (PPC) and Female Athletes First (FAF), I do hereby waive, release, and forever discharge PPC/FAF, its officers, agents, employees, assigns representatives, executors, and all others ("The released parties") from any and all responsibilities or liability from injuries or damages resulting from my participation in any activities or my use of equipment or machinery in the above mentioned activities. I do also hereby release all of the released parties and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of the released parties or any others acting on their behalf or in any way arising out of or connected with my participation in any activities of PPC and FAF or the use of any equipment at the training site. (Please initial__________).
2. I understand and am aware that sport specific training or personal fitness training/performance coaching programs such as strength and flexibility training and cardiorespiratory conditioning, including the use of equipment, are potentially hazardous activities. I also understand that fitness activities involve a risk of injury and even death. Common injuries include, but are not limited to, muscle tightness, strains, tears, inflammation and soreness. Soft connective tissue injuries may include, but are not limited to, ligament and tendon strains, tears, inflammation and soreness. Joint pain and injuries may include, but are not limited to, sprains, inflammation and soreness. Sore muscles in the core (abdominals and lower and upper back), may be a result from exercises used to focus on core stabilization and training. More serious cardiovascular complications may include, but are not limited to heart attack and stroke. I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury or death, (Please initial__________).
3. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation or use of equipment and machinery except as hereinafter stated. I do hereby acknowledge that I have been informed of the need for a physician's approval for my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I also acknowledge that is has been recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity, exercise, and use of exercise and training equipment so that I might have his/her recommendations concerning these fitness activities and equipment use. I acknowledge that I have either had a physical examination and been given my physician's permission to participate, or that I have decided to participate in activity and use of equipment and machinery without the approval of my physician and do hereby assume all responsibility for my participation and utilization of equipment and machinery in my activities.
4. I understand and am aware that when I purchase exercise programs on-line from PPC/FAF, I may be performing these exercises in-home without on-site supervision from a PPC/FAF personal fitness trainer/performance coach. I have voluntarily purchased these programs after reading and accepting an Exercise Readiness Questionnaire (ERQ) and Release of Liability. I understand that I have been instructed to perform all the exercises in the presence of an informed adult, parent, teacher or coach. I have been instructed to use a spotter when using heavy weights. I also have knowledge that the in-home exercise programs that can be purchased on-line from PPC/FAF will come with complete and detailed instructions and protocols by which to perform them. I must follow all exercise instructions and protocols as strictly advised. I am voluntarily participating in these activities and have knowledge of the dangers involved. I herby agree to expressly assume and accept any and all risks of injury or death. I do also hereby release PPC/FAF and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, arising out of or connected with my voluntary participation in any of the activities or exercise programs that I voluntarily purchased and performed in-home without a PPC/FAF personal fitness trainer/performance coach on site. (Please initial_________).
5. I understand and am aware that I am responsible for the upkeep and care of in-home exercise equipment and/or training aids that I have decided to purchase voluntarily, outside of PPC/FAF, for my in-home training. I understand that such equipment must be checked periodically for wear and tear. The types of equipment may include an airball, dumbbells, medicine balls and tubing bands. Examples of faulty equipment include: small tears in tubing bands that would make them weak and rip and small leaks in an airball that would cause the ball to lose pressure and deflate. If this type of wear and tear exists then the item must be replaced immediately. I understand that the use of such in-home equipment involves the risk of injury or death. I hereby agree to expressly assume and accept any and all risks of injury or death that may arise out of my neglect of or care of my in-home equipment and/or training aids. (Please initial_________).
Client or Guardian Signature:________________________________Date:___________
|