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 : Exercise and physical activity involves an inherent risk of injury. I hereby waive, release and discharge Juan Lopez Fitness and Oxsalon of any and all liability related to, arising from, or in any way connected with my participation in Juan Lopez fitness programs/classes, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. Further you agree to exempt Juan Lopez Fitness from attorneys fees and defense cost. *
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.