Description of Potential Benefits.Β I understand that a regular exercise program has been shown to have definite benefits to general health and well-being. I know that some of the physiological benefits of a regular exercise program can include loss of weight, reduction of body fat, improvement of blood lipids, lowering of blood pressure, improvement in cardiovascular function, reduction in risk of heart disease, improved strength and muscular endurance, improved posture, and improved flexibility. I further understand that regular exercise can have psychological benefits, often improving oneβs outlook and feeling of well-being, as well as relieving tension and stress. Client Responsibilities I understand that it is my responsibility to:
Description of Potential Benefits.Β I understand that a program of regular exercise for the heart and lungs, muscles, and joints has many associated benefits. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in psychological function, and a decrease in risk of heart disease. I have read the foregoing information and understand it. Any questions that may have occurred to me have been answered to my satisfaction. I understand that I am free to withdraw from this program without prejudice at any time I desire. I am also free to decline answering specific item or questions during interviews or when filling out questionnaires. The information that is obtained will be treated as privileged and confidential and will not be released or revealed to any person other than my physician without my expressed written consent. The information obtained, however, maybe used for statistical or scientific purpose with my right or privacy retained. Signature / Date: H & F: Par-Q: 3/08 Yes No Have you ever had? Yes No Has any immediate family (or grandparents) had? Yes No Have you recently had? π π High Blood Pressure π π Heart Attack(s) π π Chest Pain/Discomfort? π π Any Heart Trouble π π High Blood Pressure π π Shortness of Breathe π π Disease of the Arteries π π High Cholesterol π π Heart Palpitations π π Varicose Veins π π Stroke π π Skipped Heart Beats π π Lung Disease π π Diabetes π π Cough on Exertion π π Asthma π π Congenital Heart Disease π π Coughing Up Blood π π Kidney Disease π π Heart Operation(s) π π Dizzy Spells π π Hepatitis π π Early Death π π Frequent Headaches π π Diabetes π π Mental Illness π π Frequent Colds π π Heart Murmur π π Specify Mental Illness π π Back Pain π π Arthritis π π Depression π π Mental Health Treatment π π Orthopedic Problems οΏ½οΏ½ π Other Family Issues π π Anxiety Past History Score Family History Score Present Symptom Score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . π π Have you been diagnosed with/had: If yes, please indicate when and other requested details. Diabetes π Type 1 π Type II π HBA1C Score π π High Blood Pressure Date and results of last reading π π Cancer π π Lung Disease π π Heart Attack π π Stroke π π Neuromuscular Conditions (Xxxxxxxxxβx, Multiple Sclerosis, etc.)
Description of Potential Benefits.Β I understand that a regular exercise program has been shown to have definite benefits to general health and well-being. I know that some of the physiological benefits of a regular exercise program can include loss of weight, reduction of body fat, improvement of blood lipids, lowering of blood pressure, improvement of cardiovascular function, reduction in risk of heart disease, improved strength and muscular endurance, improved posture and improved flexibility. I further understand that regular exercise can have psychological benefits, often improving oneβs outlook and feeling of well-being, as well as relieving tension and stress. Client Responsibilities: I understand that it is my responsibility to: β’ Fully disclose any health issues (including diabetes, heart problems, seizures, and asthma) or medications that are relevant to participation to a strenuous exercise program. β’ Inform the trainer if there are activities with which I do not feel comfortable. β’ Cease exercise and report promptly any unusual feelings (e.g. chest discomfort, nausea, difficulty breathing, apparent injury) during the exercise program. β’ Clear my participation with my physician.
Description of Potential Benefits.Β I understand that a program of regular exercise for the heart, lungs, muscles and joints, has many benefits associate with it. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in physiological function, and a decreased risk in heart disease. I have read the foregoing information and understand it. Any questions that may have occurred to me have been answered to my satisfaction. ____________________________________________ _____________________________________________ Client Signature Date Trainer signature Date ____________________________________________ ____________________________________________ Client (Print) Trainer
Description of Potential Benefits.Β I understand that a regular exercise program has been shown to have definite benefits to general health and well-being. I know that some of the benefits can include loss of weight, reduction of body fat, improvement of blood lipids, lowering of blood pressure, improvement of cardiovascular function, reduction in the risk of heart disease, improved strength and muscular endurance, improved posture, and improved flexibility.
