Complete Waiver Form - Quickfitness

PAR-Q+

The Physical Activity Readiness Questionnaire for Everyone

The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.

GENERAL HEALTH QUESTIONS

Please read the 7 questions below carefully and answer each one honestly: check YES or NO.

Has your doctor ever said that you have a

heart condition ? high blood pressure ?

Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

Yes No

Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

Yes No

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? PLEASE LIST CONDITION(S) HERE:

Are you currently taking prescribed medications for a chronic medical condition? PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?

Yes No

Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. PLEASE LIST CONDITION(S) HERE:

Has your doctor ever said that you should only do medically supervised physical activity?

Yes No

If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

Start becoming much more physically active - start slowly and build up gradually.
Follow Global Physical Activity Guidelines for your age (https://www.who.int/publications/i/item/9789240015128).
You may take part in a health and fitness appraisal.
If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.
If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.
I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

Name

Date

Signature

Witness

SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER

If you anuswered YES to one or more of the questions above, COMPLETE PAGES 2 AND 3.

1. Do you have Arthritis, Osteoporosis, or Back Problems?
If the above condition(s) is/are present, answer questions 1a-1c lfNOO go to question 2

Yes No

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes No

Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

Yes No

Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

Yes No

2. Do you currently have Cancer of any kind?
If the above condition(s) is/are present, answer questions 2a-2b If NO O go to question 3

Yes No

Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?

Yes No

Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?

Yes No

3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm
If the above condition(s) is/are present, answer questions 3a-3d If NO O go to question 4

Yes No

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes No

Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction)

Yes No

Do you have chronic heart failure?

Yes No

Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

Yes No

4. Do you currently have High Blood Pressure?
If the above condition(s) is/are present, answer questions 4a-4b If NO O go to questions

Yes No

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
(Answer NO if you are not currently taking medications or other treatments)

Yes No

Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?
(Answer YESif you do not know your resting blood pressure)

Yes No

5. Do you have any Metabolic Conditions? This Includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes
If the above condition(s) is/are present, answer questions 5a-5e If NO go to question 6

Yes No

Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician≠ prescribed therapies?

Yes No

During activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability,abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.

Yes No

Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?

Yes No

Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?

Yes No

Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

Yes No

6. Do you have any Mental Health Problems or Leaming Difficulties?
This includes Alzheimer's, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome If the above condition(s) is/are present, answer questions 6a-6b If NO O go to question 7

Yes No

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
(Answer NO if you are not currently taking medications or other treatments)

Yes No

o you have Down Syndrome AND back problems affecting nerves or muscles?

Yes No

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure
If the above condition(s) is/are present, answer questions 7a-7d If NO O go to question 8

Yes No

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes No

Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

Yes No

If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

Yes No

Has your doctor ever said you have high blood Pressure in the blood vessels in your lungs?

Yes No

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia
If the above condition(s) is/are present, answer questions 8a-8c If NO O go to question 9

Yes No

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
(Answer NO if you are not currently taking medications or other treatments)

Yes No

Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?

Yes No

Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?

Yes No

9. Have you had a Stroke? This includes Transient /schemic Attack (TIA) or Cerebrovascular Event
If the above condition(s) is/are present, answer questions 9a-9c If NO O go to question 1O,

Yes No

Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?
(Answer NO if you are not currently taking medications or other treatments)

Yes No

Do you have any impairment in walking or mobility?

Yes No

Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

Yes No

10. Do you have any other medical condition not listed above or do you have two or more medical conditions?
If you have other medical conditions, answer questions 1Oa-1Oc If NO read the Page 4 recommendations

Yes No

Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?

Yes No

Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?

Yes No

Do you currently live with two or more medical conditions?

Yes No

PLEASE LIST YOUR MEDICAL CONDitiON(S)

AND ANY RELATED MEDICATIONS HERE:

If you answered YES to one or more of the follow-up questions about your medical condition:
You should seek further information before becoming more physically active or engaging in a fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information.

A Delay becoming more active if:

You are currently experiencing a temporary illness, such as a cold or fever. It is best to wait until you feel better.
You are pregnant. In this case, talk to your health care practitioner, physician, qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.
Your health changes. Talk to your health care practitioner, physician, or qualified exercise professional before continuing with any physical activity program.

If You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted.
The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire, consult your doctor prior to physical activity.

PARTICIPANT DECLARATION

All persons who have completed the PAR-Q+ please read and sign the declaration below.
If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

NAME

DATE

SIGNATURE

WITNESS

SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER

For more information, please contact
www.eparmedx.com
Email: eparmedx@gmail.com
Citation for PAR-Q+
Warburton DER, JamnikVK, Bredin SSD, and Gledhill Non behalf of the PAR-Q+ Collaboration. The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and Electronic Physical Activity Readiness Medical Examination (ePARmed-X+). Health & Fitness Journal of Canada 4(2):3-23, 2011.

The PAR-Q+ was created using the evidence-based AGREE process (1) by the PAR-Q+ Collaboration chaired by Dr. Darren E. R. Warburton with Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Donald c.McKenzie (2). Production of this document has been made possible through financial contributions from the Public Health Agency of Canada and the BC Ministry of Health Services. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada or the BC Ministry of Health Services.

Key References

1. JamnikVK, Warburton DER, Makarski J, McKenzie DC, Shephard RJ, Stone J, and Gledhill N. Enhancing the effectiveness of clearance for physical activity participation; background and overall process. APNM 36(51):53-513, 2011.
2. Warburton DER, Gledhill N, JamnikVK, Bredin SSD, McKenzie DC, StoneJ, Charlesworth5, and Shephard RJ. Evidence-based risk assessment and recommendations for physical activity clearance; Consensus Document. APNM 36(51):5266-s29B, 2011.
3. Chisholm DM, Collis M Kulak LL, DavenportW, and Gruber N. Physical activity readiness. British Columbia Medical Journal. l 975;17:375-378.
4. Thomas 5, Reading J, and Shephard RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Canadian Journal of Sport Science 1992;17:4 338-345.

Guest Info + Waiver Agreement

Last Name

Address

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City

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Phone No

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Are you insured for any of the following services? (Check all that apply)

Physiotherapy Chiropractic Care Massage Therapy

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Emergency Contact Phone

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Terms & Conditions

Guest Health Warranty: Quick Fitness shall not be liable for any injury arising out of the guest's disability, impairment, and/or aliment preventing him or her from engaging in active of passive exercise, or that would be detrimental or adverse to such person's health, safety, and/or physical condition if he or she chooses to participate. Each member and guest should be aware of his/her medical history and should consult with a physician prior to engaging in exercise or continuing to exercise if a medical condition appears to be developing/has developed.
activity/function that is operated, arranged, or sponsored by Quick Fitness. It shall be the obligation of the guest to pay for any costs involved upon presentation of a statement thereof. Any and all use of equipments of Quick Fitness by the guest shall be at such person's own risk, and Quick Fitness shall not be liable for any injuries or damages to such person or the property of such person or be subject to any claim, demand , injury, and/or damages. The guest or anyone or anyone on behalf of the guest's personal representative, heirs, administrators, assings, and successors does here by expressly forever release and discharge at Quick Fitness, its successors, and assings, as well as its officers, agents, and employees from all such claims, demands, actions or cause of actions. Months where a member does not use the gym will not be refunded/ added on or extended to a membership.

By checking this box I agree to the terms and conditions above & acknowledging that this is your signed agreement.