Sign up form PAR-Q Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Email Address Emergency Contact Details Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Health Goals What health/skill goal would you like to achieve in the next three months? Name 3 things you could do to improve your health/skill What are your main reasons for starting a fitness/martial arts programme? General Conditioning Weight/Fat Loss Stress Management Wish to Compete Muscular Strength Aerobic Fitness Flexibility Self-Defence No Time Appearance Improve Self-Esteem How would you describe your general health and fitness? Have you ever done any structured exercise? If “Yes”, What did you do? What types of exercise did you enjoy the most? What types of exercise did you dislike the most? What would you say are the main barriers stopping you from exercising? Lack of Facilities Injury/Illness Lack of Knowledge No Motivation Unfit Family No Time Appearance Work Diet and Nutrition On a scale of 1-10 (with 1 being poor and 10 being excellent) how would you assess the quality of your eating habits? Would you like any help or advice in changing the quality of your eating habits? Yes No Do you follow any particular diet or eating patterns Yes No Lifestyle Do you drink alcohol? Yes No Do you smoke? Yes No If you answered ‘Yes’, would you like help or advice to change these habits? Yes No Medical History Have you had a major illness or injury in the last 5 years? Yes No If ‘Yes’ please give details Are you receiving treatment for any diagnosed medical condition? Yes No If ‘Yes’ please give details Are you taking any prescription medication? Yes No If 'Yes' please give details Please indicate if you ever experience any of the following symptoms: Do you ever get unusually short of breath with very light exertion? Yes No Do you experience pain, pressure, heaviness or tightness in the chest area? Yes No Do you experience unexplained pain in the abdomen, shoulders or arm? Yes No Do you experience severe dizzy spells or episodes of fainting? Option 1 Option 2 Do you regularly experience lower leg pain during walking that is relieved by rest Yes No Do you experience palpitations or irregular heartbeats? Yes No Are you currently pregnant or have you given birth in the last 6 months? Yes No Structural health Please indicate any aches, pains or problem areas. Please give details of any areas indicated Are any of these injuries aggravated by exercise? Yes No Are you currently receiving treatment for any structural problem? Yes No Please indicate any other health problems you suffer from which you have not already mentioned. I can confirm that I have answered all questions honestly and that the information given is correct. Print Signature: Print Name Date MM DD YYYY Note: This PAR Q becomes invalid should your condition change Assumption of risk waiver I have read and agree with the above assumption of risk waiver of claim & release of liability Yes No Gym user agreement GDPR data protection I have read and agree with both the gym user agreement and the GDPR data protection policy * Agree Print Signature Print Name Date MM DD YYYY Thank you!
