PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

Name *
Name
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *
Do you feel pain in your chest when you perform physical activity? *
In the past month, have you had chest pain when you were not performing any physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *
Do you know of any other reason why you should not engage in physical activity? *
Health : If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. *
Waiver : In considerations of gaining access to participate in activities associated with Juan Lopez Fitess at CROSSFIT ALINEA, I hereby waive, release and forever discharge CROSSFIT ALINEA and Juan Lopez Fitness (Juan Lopez), it’s officers, instructors, agents, employees, representatives, or executors for all responsibilities or liability for death, injuries or damages resulting from my participation in any activities in said program, including death or any injuries or damages resulting from negligence of CROSSFIT ALINEA and Juan Lopez Fitness or its instructors, officers, agents, employees, representatives, or executors. Trainer has advised me prior to my commencement of participation in cardiovascular and resistance training programs that such participation could result in serious injury or death, including broken bones; strained or torn muscles, ligaments, or tendons; herniated disc; cardiovascular or cerebrovascular events, including heart attack or stroke; and injuries due to overexertion, including rhabdomyolysis. I freely and knowingly assume these risk, and I hereby waive any right, claim or cause of action against Juan Lopez (Juan lopez Fitness) and release Juan Lopez (Juan lopez Fitness) from any liability for any injury, cost, damage, or expense which might occur as a direct or indirect result of my participation in this cardiovascular and resistance-training program, including those resulting from the negligence of Juan Lopez (Juan lopez Fitness). I have read this form, understand and agree with each of the foregoing point. *
Cancellation Policy : Juan Lopez Fitness requires a 48 hours advance written notice for canceling or rescheduling a training session. If the 48 hour window is missed, then the client forfeits their session. *
Session Etiquette : The client understands that a time slot is being reserved, and agrees to be properly clothed and ready for training within 10 minutes of the time slot reserved. If a client is more than 10 minutes late for a reserved session, the trainer is not obligated to extend the session over the reserved time slot to make up the time lost, and the trainer also reserves the right to forfeit the session. *
Agreement : I have read the above carefully, and by electronically submitting this form I agree to comply with all of the above.