Medical History

Medical History Form

Full Name

Address

Suite, Apt, Floor, Etc.

City

State

Zip

Date of Birth

Body Weight

Phone Numbers

Home

Work

Mobile

Email Address

PAR-Q Physical Activity Readiness Questionnaire

For most people physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.

Common sense is your best guide in answering these few questions. Please read them carefully and check the yes or no opposite the question if it applies to you.

1. Has your doctor every said you have heart trouble?

Yes

2. Do you frequently have pains in your heart and chest?

Yes

3. Do you often feel faint or have spells of severe dizziness?

Yes

4. Has a doctor ever said your blood pressure was too high?

Yes

5. Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be made worse with exercise?

Yes

6. Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?

Yes

7. Are you over age 65 and not accustomed to vigorous exercise?

Yes

If you answered YES to one or more questions...

If you have not recently done so, consult with your personal physician by telephone or in person before increasing your physical activity and/or taking a fitness test.

If you answered NO to all questions...

If you answered PAR-Q accurately, you have reasonable assurance of your present suitability for exercise.

Medical History

Please list any health history/concerns that could possibly affect our workout programming (it is always better to provide too much information, rather than too little... in other words, if your not sure write it down).

Exercise History

Please list any exercise, sports or other activities that may give us a better idea of your physical and mental abilities (Please be specific: Do you currently participate in this activity? How long? How frequently? Experience level? etc...)

Goals

What do you want to accomplish by working out with a trainer at EVOLVEEXERCISE? Is there a target date for which you want to accomplish these goals?

Commitment and Limiters

What are you willing to commit to in order to attain your goals? What are potential limiters that you can forsee as obstacles in your quest to achieve these goals?

Rules, Regulations and Policies

1) There is a Reciprocal 12 Hour Cancellation Policy. If you cancel a workout session with less that 12 hours noticed you will be charged for that session and if we cancel a workout session on you with less than 12 hours you will be credited 1 session.

2) Please refrain from distracting those people (trainers and members) who are working out. This means absolutely no mobile phone use, non-workout related conversation or other disruptive behavior is acceptable on the gym floor.

3) At EVOLVEEXERCISE safety is our top priority and we pride ourselves in the use of safe, effective exercise. All exercises must be performed in the form that your instructor has instructed you to use. This means no abrupt, fast movements, dropping of the weights or any other discrepancies from the form in which you were instructed to use. If you are unable or unwilling to maintain impeccable exercise form your instructor will have no alternative but to terminate the exercise and possibly the workout.

4) If for any reason you are ever dissatisfied with the service you receive here at EVOLVEEXERCISE, please contact Rick Sullivan at 516-749-4991 or by e-mail at rick@evolveexercise.org.

Our goal is to provide you with the best service possible and your continuous feedback will help us attain that goal. Thank You!

By printing you name and dating this document below you agree that you have read and understand the above listed rules, regulations and policies and agree to abide by them. Additionally, you certify that all information provided is true and complete to the best of your knowledge. You further understand that, as with any exercise program, there is a risk of injury or even death and release EVOLVEEXERCISE and all its representatives from any liability now and in the future.