PARQ & consent form

Please fill out the following form.

full name

phone number

date of birth

Month

Day

Year

Email

emergency contact name:

emergency contact number:

do you have heart disease or a history of this in your parents or siblings prior to the age of 35?

yes

no

are you currently receiving any medical treatment or medication?

yes

no

if you ticked yes to any of the above, please provide further and more specific information:

for women specifically: are you or do you think you could be pregnant?

yes

no

have you given birth in the last 6 months?

yes

no

were there any medical complications or injury that you're aware of from this:

have you had a major illness or injury in the last 5 years?

yes

no

if yes, please provide further and more specific information:

are you receiving treatment for any newly diagnosed medical condition?

yes

no

if yes, please provide further and more specific information, incl whether you have received agreement from your dedicated health professional to engage in such activities as exercise and specifically, boxercise group class or circuit class.

are you taking any prescription medication?

yes

no

if yes, please provide further and more specific information:

SYMPTOMS: please indicate whether you experience or have ever experienced any of the following symptoms?

do you ever get unusually short of breath with light exertion?

chest area?

do you ever experience pain, heaviness or tightness in your

do you ever experience any unexplained pain in your abdomen, shoulder(s) or arm(s)?

do you ever experience severe dizzy spells or episodes of fainting?

do you ever regularly experience lower leg pain during walking that is not relieved with rest?

do you ever experience palpitations or irregular heartbeats?

please advise of any further information or concerns you feel may be relevant to you participating in a Boxercise class or Boxercise Circuits class?

CONSENT:

I hereby confirm that I have answered all questions honestly and that the information given is correct.

I understand that the trainer (Alex Brooks) is not able to provide me with medical advice and is neither qualified to diagnose or prescribe with regard to my medical fitness, and that this information is used as a guideline to the limitations of my ability to exercise. I am aware that if I have answered yes to any of the questions above, I will seek medical advice to confirm I am fit to participate in either the Boxercise or Boxercise Circuits classes before I attend these.

I have answered the above questions to the best of my ability, and I waive any legal recourse for damage to myself or property arising from participation.

name / signature

date:

*Please ensure that you fill out a PARQ and consent form prior to attending your first class or 1:1 session. (along with when things change with your health and general fitness) Failure to do this will result in you not being able to participate in the class, this is for your own safety.

PARQ & consent form