Bodyfaze Par-Q & Lifestyle Questionnaire

1

Please verify that you are human* This field is required

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2

Name* This field is required

First Name

Last Name

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3

Email* This field is required

example@example.com

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Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Mobile Phone Number* This field is required

Area Code

Phone Number

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6

Emergency Contact Number

Area Code

Phone Number

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PAR-Q* This field is requiredSome people should check with their doctor before commencing an exercise program, common sense is your best guide when answering this questionnaire. Please read the questions carefully and answer honestly Please mark YES or No to the following: Hasyour doctor ever said that you have a heart condition and recommended only medically supervised physical activity?

YESNO

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Do you have pains in your chest when you perform physical activity?* This field is requiredPAR-Q

YESNO

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Have you had chest pain when you were not doing physical activity?* This field is requiredPAR-Q

YESNO

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Do you lose your balance due to dizziness or doyou ever lose consciousness?* This field is requiredPAR-Q

YESNO

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11

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e.diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anaemia, epilepsy, respiratory ailments, back problems, etc.?* This field is requiredPAR-Q

YESNO

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12

Are you pregnant now or have given birth within the last 6 months?* This field is requiredPAR-Q

YESNO

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13

Have you had a recent surgery?* This field is requiredPAR-Q

YESNO

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Is your doctor currently prescribing drugs for your blood pressure or heart Condition?* This field is requiredPAR-Q

YESNO

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15

Do you take any medications, either prescription or non-prescription, on a regular basis?* This field is requiredPAR-Q

YESNO

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What is the medication for?PAR-Q

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How does this medication affect your ability to exercise or achieve your fitness goals? PAR-Q

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If you answered YES to one or more questions. Talk to your doctor BEFORE you become physically active or have a fitness appraisal. Discuss with your doctor which kinds of activities you wish to participate in. Please elaborate further.PAR-Q

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If you answered NO to all the questions you can be reasonably sure that you can:

· Start becoming more physically active – start slow and build up

· Take part in a fitness appraisal – this is a good way to determine your basic fitness level. It is recommended that you have your blood pressure evaluated.

However, delay becoming more active if:

· You are not feeling well because of temporary illness such as cold or flu.

· If you are or maybe pregnant – talk to your doctor first.

Please Note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

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Other Health Questions* This field is requiredAs overall wellness is important to us, Its important for us to delve a little deeper with these questions as your health and well being is of utmost importance to us. These questions are necessary if applicable.

Yes I have lower back pain?

Yes I have upper back pain or shoulder pain

Yes I suffer neck pain

Yes I have pelvic floor issues

Yes I wee myself on high impact exercises

Yes I wee myself when i sneeze

Yes I suffer constipation

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How we will contact you* This field is requiredTo contact you and keep you updated of cancellations, updates or events we use the following options. Please note that we CANNOT contact you if you DO NOT tick any of the options below: .

Yes I agree to be added to your mailing list?

Yes I agree to be added to your social media ie: facebook, Instagram

Yes I agree to be added to your CLOSED facebook group for tips, recipes and education?

Yes I agree to be contacted by Text

Yes I agree to be contacted by Whatsapp

Yes i agree to be added to your Whatsapp group? - this group is used only for class times and cancellations, not a chat line.

Yes i agree for you to use photographs or videos for publicity purposes? permission will be taken before hand.

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BMI CalculatorIf you are not sure of your height in cm press NEXT and to see the height converter, then press PREVIOUS to comeback and fill in this form.

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Height ConverterNow press PREVIOUS to fill in the BMI form. or NEXT to continue

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Privacy Statement* This field is requiredPrivacy Statement and what we do with your data In short: we respect your privacy and do not share you’re your details with anyone else. For our full Privacy policy, please see our website www.bodyfaze.com/cookie-policy/ Or this can be requested from us. Please note: Your records will be kept for 7 years from your last contact with us in accordance with ICO/GDPR regulations which came into force on the 25th May 2018 and as stipulated by our insurance company. PLEASE NOTE: If you are absent, please be aware that it is in our nature to be concerned for you, the close relationships and bonds that we build mean that we will try to contact you to express our concerns. If you wish to cease training, please can you get in contact or send us an email to hello@bodyfaze.com to express your feelings and we would very much appreciate any feedback. We obviously have your well-being in mind and would welcome your return at any time in the future.

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25

SignaturePlease Sign

Clear

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NewsletterThank you for subscribing to our Newsletter, You will receive confirmation by Email. Should you wish to unsubscribe at any time, please follow the unsubscribe prompt at the bottom of each email.

Yes, subscribe me to this newsletter.

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Follow UsCLICK the Facebook icon to join our Bodyfaze Group. This is where we really connect with you on all matters or health and fitness. These are our open to public groups, where we post tips, nutrition, class details and much more. Once you have joined this group, we are able to add you to the CLOSED facebook group where we DIG much DEEPER.

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* This field is required

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