Personal Training Questionnaire

Physical Activity Readiness Questionnaire (PARQ)

Name
*

First

Last
*

Last

Email
*

Height
*

Weight
*

Date of birth
*

Age
*

Gender
*

Physicians name

Physicians phone number

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
*

yes

no

how did you hear about us?
*

Do you feel pain in your chest when you perform physical activity?
*

yes

no

In the past month, have you had chest pain when you were not performing any physical activity?
*

yes

no

Do you lose your balance because of dizziness or do you ever lose consciousness?
*

yes

no

Do you have a bone or joint problem that could be made worse by a change in your physical activity?
*

yes

no

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
*

yes

no

Do you know of any other reason why you should not engage in physical activity?
*

yes

no

Occupational Questions

What is your current occupation?

Does your occupation require extended periods of sitting?

yes

no

Does your occupation require extended periods of repetitive movements?

yes

no

Does your occupation require you to wear shoes with a heel (dress shoe)?

yes

no

Does your occupation cause you anxiety (mental stress)?

yes

no

Medical Questions

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc)? If yes, please explain

Have you ever had any surgeries? If yes, please explain

Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? if yes explain

Are you currently taking any medication? If yes please list

Recreational Questions

Do you partake in any recreational activities (golf, tennis, skiing, etc)? If yes, please explain

Do you have any hobbies (reading, gardening, working on cars, exploring the internet, etc)? if yes, please exlpain

Waiver of Liability

By submitting this form I am aware that PT Fitness services are provided in various locations. Using any of the facilities involves the risk of injury to you or your guest, whether you or someone else causes it. Specific risks vary from one activity to another and the risks range from minor injuries to major injuries, such as catastrophic injuries including death. In consideration of your participation in the activities offered by PT Fitness, you understand and voluntarily accept this risk and agree that PT Fitness, its officers, directors, employees, volunteers, agents, independent contractors and facility will not be liable for any injury, including, without limitation, personal bodily, or mental injury, economic loss or any damage to you, your spouse, guests, unborn child, or relatives resulting from negligence of PT Fitness’ behalf or anyone using the facilities whether related to exercise or not. Further, you understand and acknowledge that PT Fitness does not manufacture fitness or other equipment at any of the facilities used, but purchases or leases equipment. You understand and acknowledge that PT Fitness is providing a service and may not be held liable for defective products. By signing below you acknowledge that you have read the foregoing and know of the nature of the activities and agree to all the terms of this agreement. By providing your contact information you are authorizing PT Fitness to contact you.

INDEMNIFICATION

In consideration of Tarrant Regional Water District, a Water Control and Improvement District (“the District”) granting the undersigned access to District Property, the undersigned hereby releases, relinquishes, and discharges and agrees to indemnify and hold harmless the District, and the District’s officers, directors, servants, agents and employees from any and all claims, demands, liabilities, suits, causes of action, obligations, damages, injuries, losses, penalties, costs, charges, and expenses (including, without limitation, attorney’s fees, court costs, consultant fees, expert fees, and other litigation-related expenses) of whatsoever kind or character directly or indirectly resulting from, arising out of or in connection with, or relating to (1) any condition of the District Property; (2) any use or occupation of the District Property; (3) any act of negligence, whether of omission or commission, of the undersigned or any of its officers, directors, agents, servants, employees, contractors, subcontractors, or any other person acting on behalf of the undersigned; (4) any damage to the property of the undersigned which may arise in connection with the District’s operation and maintenance of said District Property; (5) any accident, injury, or damage whatsoever caused to any person, firm, corporation, or property. This indemnification extends to and includes any an all claims for bodily injury, death, sickness, disease, property damage or destruction, consequential damage, or economic loss caused to or suffered by any person or property, including, but not limited to the undersigned, and any officers, directors, agents, servants, employees, contractors, subcontractors, or any other person acting on behalf of the undersigned, or any other person or entity. In case of any action or proceeding brought against the District by reason of any such claim the undersigned, upon notice from the District, agrees to defend the action or proceedings by counsel acceptable to the District at the cost of the undersigned. THE PROVISIONS OF THIS RELEASE AND INDEMNIFICATION SHALL REMAIN AND BE IN FULL FORCE AND EFFECT EVEN IF ANY CLAIM, DEMAND, LOSS, LIABILITY, DAMAGE, OR EXPENSE, OR CLAIM THEREFOR, BY ANY PERSON OR ENTITY, DIRECTLY OR INDIRECTLY RESULTS FROM, ARISES OUT OF, OR RELATES TO, OR IS ASSERTED TO HAVE RESULTED FROM, ARISEN OUT OF, OR BE RELATED TO, IN WHOLE OR IN PART, ONE OR MORE NEGLIGENT ACTS OR OMISSIONS OF THE DISTRICT, OR ANY OF THE DISTRICT’S OFFICERS, DIRECTORS, AGENTS, SERVANTS, EMPLOYEES, OR ANY OTHER PERSON OR ENTITY ACTING ON BEHALF OF THE DISTRICT, THE PARTIES INTENDING HEREBY TO SATISFY THE EXPRESS NEGLIGENCE DOCTRINE. This indemnification shall survive termination or expiration of this Permit.