PHYSICAL ACTIVITY READINESS QUESTIONNAIRE Physical activity should not be hazardous for most people. The PAR-Q has been designed to identify those individuals who should seek medical attentions prior to beginning a physical fitness program. Please answer all questions accurately and honestly to allow us to fully determine your individual needs. * Each field is required. Full Name Your Email Full Address Cell Phone Age Height Weight Emergency Contact Name Emergency Contact Number 1. Do you have high cholesterol? —Please choose an option—NoYes 2. Have you ever been diagnosed with a heart condition? —Please choose an option—NoYes 3. Have you ever been diagnosed with a bone or joint problem? —Please choose an option—NoYes 4. Have you ever been diagnosed with high or low blood pressure? —Please choose an option—NoYes 5. Have you been diagnosed with a back or neck injury? —Please choose an option—NoYes 6. Is there any other reason that would prevent you from participating in a physical fitness program? __________________________________ LIABILITY WAIVER BUYER ACKNOWLEDGMENT AND ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF LEGENDARY FITNESS AND IT’S STAFF. BUYER ACKNOWLEDGES THESE PHYSICAL ACTIVITIES INVOLVES THE INHERENT RISK OF PHYSICAL INJURIES OR OTHER DAMAGES, INCLUDING, BUT NOT LIMITED TO, HEART ATTACKS, MUSCLE STRAINS, PULLS OR TEARS, BROKEN BONES, SHIN SPLINTS, HEART PROSTRATION, KNEE/LOWER BACK/FOOT INJURIES AND ANY OTHER ILLNESS, SORENESS, OR INJURY HOWEVER CAUSED, OCCURRING DURING OR AFTER BUYER’S PARTICIPATION IN THE PHYSICAL ACTIVITIES. BUYER FURTHER ACKNOWLEDGES THAT SUCH RISKS INCLUDE, BUT ARE NOT LIMITED TO, INJURIES CAUSED BY THE NEGLIGENCE OF AN INSTRUCTOR OR OTHER PERSON, DEFECTIVE OR IMPROPERLY USED EQUIPMENT, OVER-EXERTION OF A BUYER, SLIP AND FALL BY BUYER, OR AN UNKNOWN HEALTH PROBLEM OF BUYER. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY INVOLVED WITH PARTICIPATION IN THE PHYSICAL ACTIVITIES, BUYER AFFIRMS THAT BUYER IS IN GOOD PHYSICAL CONDITION AND DOES NOT SUFFER FROM ANY DISABILITY THAT WOULD PREVENT OR LIMIT PARTICIPATION IN THE PHYSICAL ACTIVITIES. BUYER ACKNOWLEDGES PARTICIPATION WILL BE PHYSICALLY AND MENTALLY CHALLENGING, AND BUYER AGREES THAT IT IS THE RESPONSIBILITY OF BUYER TO SEEK COMPETENT MEDICAL OR OTHER PROFESSIONAL ADVICE, REGARDING ANY CONCERNS OR QUESTIONS INVOLVED WITH THE ABILITY OF BUYER TO TAKE PART IN LEGENDARY FITNESS PHYSICAL ACTIVITIES. BY SIGNING THIS AGREEMENT, BUYER ASSERTS THAT HE OR SHE IS CAPABLE OF PARTICIPATING IN THE PHYSICAL ACTIVITIES. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY FOR NOT EXCEEDING HIS OR HER PHYSICAL LIMITS. 7. By signing, I acknowledge that I have read and agree to the liability waiver: __________________________________ THE FOLLOWING INFORMATION WILL BE TREATED AS PRIVILEGED INFORMATION 1. Do you ever feel weak, fatigued, or sluggish? 2. How many meals do you eat each day? 3. How many calories do you consume daily? 4. Are you taking supplements such as vitamins, amino acids, protein shakes, etc.? 5. Do you need several cups of coffee to get you through the day? 6. Do you experience digestive difficulties often? 7. Do you feel that a properly structured nutrition and exercise program would benefit you? 8. How long have you been exercising? 9. Have you reached and maintained your goals? 10. Are you happy with the way you look and your current state of health? 11. Why is it important to you to improve your health? 12. On a scale of 1 to 10, how serious are you about achieving your goals? (1 not serious, 10 being all in) —Please choose an option—1 (Not serious)2345 (Somewhat serious)678910 (I'm ready to start) __________________________________ PLEASE LIST YOUR FITNESS GOALS 1. What is your desired body fat percentage? 2. What is your desired weight? 3. What is your desired waist size? 4. What is your desired dress or pant size? 5. How many times a week do you plan to exercise? 6. Does your spouse support your efforts in becoming physically active? SELECT ALL THAT APPLY 7. I'm interested in: Strength TrainingCardio TrainingCircuit TrainingFlexibility & Balance 8. My goal is to: Lose WeightReduce Body FatIncrease Muscle ToneIncrease EnduranceImprove Overall Health