PAR-Q - Rossell Fitness

Name*

First Last

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Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email*

Please double check before submitting

Date of birth*

Phone number*

Please double check before submitting

Name of emergency contact*

First Last

Phone number of emergency contact*

Health Questionnaire Check All That Apply*

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the last month, have you had chest pain when you were doing physical activity?
Do you lose your balance because of dizziness, or do you ever lose consciousness?
Have you had surgery in the past 6 months? If so give details (below)
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure, heart condition or other serious illnesses?
None of the above

Please go into detail about any conditions ticked above (or type NONE if this is not applicable to you)*

Do you know of any other reason (including any of the following) why you should not do physical activity?*

Please add any other information that you feel is relevant (or type NONE if this is not applicable to you)*

Please check off the exercises that you are familiar with (that you have done before)*

Consent: I confirm that I have read and understood the Contraindications (none of which apply to me), the informed consent wording and have answered “no” to all questions in the health questionnaire. I confirm that I will notify the trainer if there is any change in my health or circumstances which might impact on my ability to do physical activity. I agree to participate in this activity entirely at my own risk and understand that no liability shall be associated with Rossell Fitness Personal Training, for any injury, loss, damage or third party liability. Please note all payments made in advance for any activity or gym membership are non-refundable and no reductions are available for missed sessions on future bookings. I give my consent to Nicola to be contacted using the information I've submitted in this form.*

I confirm

Your data will be protected and never shared with third-party companies. In accordance with GDPR regulations, you are entitled to request to see what information is held about you, opt out of any communication at any time and change any information we hold. We will comply with your request within the designated time frame.

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