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Physical Activity Readiness Questionnaire
When designing a personalized fitness program custom tailored to your specific needs and goals, your safety is my number one concern. Please read the following questions carefully and answer each completely and truthfully. Physical activity should not be hazardous for a healthy individual; however, some people may need medical evaluation and advise from their physician before starting a program.
Name: _____________________________________________________ Date: ________________________
Steet: ______________________________________________________Birth date: ____________________
City: __________________________________St:_________Zip:_______Home Phone:__________________
Email: ______________________________________________________Work/Cell Phone:_______________
Emergency Contact Person:____________________________________ Phone:________________________
Do you have any other medical conditions that may effect your ability to safely participate in an exercise regimen?________________________________________________________________
Has your physician ever said you have a heart condition of any kind? _____________________________
Has your physical activity level ever been limited or monitored by a physician? ______________________
Do you smoke? ____yes ____no ___quit, how long ago? _______________________________________
Do you suffer from arthritis, joint pain or limited movement that is painful with physical activity? __________
explain _____________________________________________________________________________
Are you pregnant or recently been pregnant? __________________________________________________
Have you had any recent illnesses or operations? _______________________________________________
Do you have any broken bones, back problems or neck pain? _____________________________________
Waiver of Liability:
I,_________________________, certify and acknowledge: that Teresa L. Warner, an independent Personal Trainer, has advised me, prior to my commencement of participation in a cardiovascular, flexibility, and weight training program, that such participation could result in physical injury and even death. I freely and knowingly assume the risks in such program and I hereby waive any right, claim or cause of action against Teresa L. Warner and release her from any liability for any injury, cost, damage, expense or claim, which I or anyone on my behalf, might have as a direct or indirect result of my participation in this flexibility, cardiovascular and weight training program.__________________________ _____________________________ ______________
Print Name Signature Date