Date of Birth:

MM

DD

YYYY

Has your doctor ever said that you have bone or joint problems, such as arthritis that has been aggravated by exercise or might be made worse with exercise? *

Yes

No

Do you have high blood pressure? *

Yes

No

Do you have low blood pressure? *

Yes

No

Do you have Diabetes Mellitus or any other metabolic disease? *

Yes

No

Has your doctor ever said you have raised cholesterol (above 6.2mmol/L )? *

Yes

No

Has your doctor ever said you have a heart condition and should only do physical activity recommended by them? *

Yes

No

Do you have any muscle, joint or back disorders that could be aggravated by physical exercise? *

Yes

No

Do you have any conditions that will prevent you performing exercises including high impact moves, running, jumping, pressing, lifting and an elevated heart rate? *

Yes

No

Have you ever felt pain in your chest when you do physical exercise? *

Yes

No

Is your doctor currently prescribing you drugs or medication? *

Yes

No

Have you ever suffered unusual shortness of breath at rest or with mild exertion? *

Yes

No

Is there any history of coronary heart disease within your family? *

Yes

No

Do you often feel faint, have spells of severe dizziness or have lost consciousness? *

Yes

No

Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)? *

Yes

No

Do you currently smoke? *

Yes

No

Do you currently exercise on a regular basis (at least 3 times per week) and / or work a job that is physically demanding? *

Yes

No

Have you had root canal treatment? *

Yes

No

Are you, or is there any possibility you might be pregnant? *

Yes

No

Do you know any other reason you should not participate in a physical activity programme? *

Yes

No

Medical/Liability Waiver *

I declare that the information that I have given is true and correct and I hereby recognise the inherent risks with physical training and assume any such risks. I release Billy Morgan from all liability should anything befall me in the course of these coaching services and recognise that the advice and physical training that he provides is not meant as a substitute for the medical advice of physicians.

I understand and agree to the above

Assumption of Risk *

I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.

I understand and agree to the above

Declaration of Consent *

I have completed the Par-Q form to the best of my ability. By signing this I agree that all the information above is correct as of today's date and that if there are any changes to my health I will notify Movementum and if I am ever in doubt about something I hereby agree to communicate clearly in asking for help.

I understand and agree to the above

Privacy Policy *

We do not share any of your information with any third parties or profit from you personal information and data. Our Privacy Policy is at the bottom of each page.

I understand and agree to the above

Date Today: *

MM

DD

YYYY