Sign - Physical Activity Assessment and Waiver

Physical Activity Assessment and Waiver

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

* 1. Has your doctor ever said that you have a heart condition OR high blood pressure?

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

* 3. 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).

* 4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

PLEASE LIST CONDITION(S) HERE:

* 5. Are you currently taking prescribed medications for a chronic medical condition?

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:

* 6. 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? 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:

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

If you answered NO to all of the questions above, you are cleared for physical activity.

•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.

Delay becoming more active if:

•If you have a temporary illness such as a cold or fever; it is best to wait until you feel better.

•If you are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.

•Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a qualified exercise professional before continuing with any physical activity program.

If you answered YES to one or more of the questions above

Complete the following questions

FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S)

Please read the questions below carefully and answer each one honestly

1. Do you have Arthritis, Osteoporosis, or Back Problems?

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

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)?

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

2. Do you currently have Cancer of any kind?

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

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

3. Do you have a Heart or Cardiovascular Condition? (This includes Coronary Artery Disease, Heart Failure, or Diagnosed Abnormality of Heart Rhythm)

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)

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

Do you have chronic heart failure?

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

4. Do you currently have High Blood Pressure?

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)

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

5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes

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

Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or 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.

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?

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

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

6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome

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)

Do you have Down Syndrome AND back problems a$ecting nerves or muscles?

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure

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)

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

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?

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

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia

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)

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

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

9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event

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)

Do you have any impairment in walking or mobility?

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

10. Do you have any other medical condition not listed above or do you have two or more medical conditions?

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?

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

Do you currently live with two or more medical conditions?

PLEASE LIST YOUR MEDICAL CONDITION(S) AND ANY RELATED MEDICATIONS HERE:

If you answered NO to all of the FOLLOW-UP questions (pgs. 2-3) about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

•It is advised that you consult a qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs.

•You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate-intensity exercise,

•3-5 days per week including aerobic and muscle-strengthening exercises.

•As you progress, you should aim to accumulate 150 minutes or more of moderate-intensity physical activity per week.

•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 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.

Delay becoming more active if:

•If you have a temporary illness such as a cold or fever; it is best to wait until you feel better.

•Your health changes - talk to your doctor or qualified exercise professional before continuing with any physical activity program.

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.

ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT DECLARATIONS

This Agreement is entered into between personal trainer and coach, Kim Basler (“Coach”) and the undersigned (“Client”). The provision of personal training services by Coach to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement.

ASSUMPTION OF RISK: You agree that if you engage in any physical exercise or activity, including personal training, or equipment you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided to you by Coach or otherwise, including injuries or damages arising out of the negligence of Coach.

Your assumption of risk includes, but is not limited to, your use of any exercise equipment mechanical or otherwise). You assume the risk of your participation in any activity, class, program, instruction, or event, including but not limited to stretching, weightlifting, walking, jogging, running, or aerobic activities. You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury, illness, damage, or loss.

RELEASE: You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Coach (and Coach’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Coach, whether active or passive, or any of Coach’s affiliates, employees, agents, representatives, successors, and assigns. This waiver and release of liability include, without limitation, injuries which may occur as a result of (a) your use of any exercise equipment which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including personal training.

INDEMNIFICATION: By execution of this agreement, you hereby agree to indemnify and hold harmless Coach from any loss, liability, damage, or cost Coach may incur due to the provision of personal training by Coach to you.

ACKNOWLEDGMENTS: You expressly agree that the foregoing release, waiver, assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by the law of Canada and its provinces, including Ontario. You acknowledge that Coach offers a service to his/her clients encompassing the entire recreational and/or fitness spectrum. This release is not intended as an attempted release of claims of gross negligence or intentional acts. You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk and indemnity agreement. You are aware and agree that by executing this waiver and release, you are giving up your right to bring legal action or assert a claim against the coach for the coach’s negligence.

You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.

* I declare that I have read and understood the Assumption of Risk, Release of Liability, and Indemnity Agreement Declarations above

* Print Name:

* Date:

•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.

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