If You Answered YES to One Or More Questions

BOOT CAMP PAR-Q FORM

It is recommended to share some confidential and personal information, at your discretion, openly and honestly in this document. I will honour and protect your privacy and confidentiality of any communications and personal information shared with me. Your personal information will not be shared with any person or organization including your employer, physician, or health care provider without your written permission. At any time you can add or delete personal information.

PERSONAL DETAILS

NAME ______DOB ______AGE _____

EMERGENCY CONTACT NAME: EMERGENCY CONTACT TEL NO:

______

MEDICAL HISTORY YES NO Please tick Yes or No 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity when recommended by a doctor? 2. Do you feel pain in your chest when you do physical activity?

3. In the past month, have you had chest pain when you were not doing physical activity?

4. Do you lose balance because of dizziness or do you ever lose consciousness?

5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? 6. Is your doctor currently prescribing you drugs (for example water pills) for your blood pressure or heart condition? If yes, please name them below if possible:

7. Do you know any other reason why you should not do physical activity? If yes, please state reason below:

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active. Tell your doctor about the PAR-Q and which questions you answered YES. -You may be able to do any activity you want — as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

Informed Consent and Liaibility Waiver

By signing below, I confirm that I have answered honestly all of the questions on this document. I understand that there is an element of risk involved with any physical activity and that these sessions are designed in such a way to minimise the risk of injury. However, I am taking part at my own risk and release Joanne Shrewsbury, GI-JO Fitness or anyone associated with GI-JO Fitness from any liaibility for any injuries or damages that may incur whilst participating in the Bootcamp session. If at any time during the session I feel discomfort or pain, I understand that I should notify the instructor immediately. I will make the instructor aware of any illness/injuries that I have and if necessary, will seek advice from my GP to ensure that I am able to participate in the Boot Camp. I know and accept the risks, and assume responsibility for my actions and confirm that my participation in the Bootcamp is entirely voluntary and I may opt out at any given time if I so wish.

Signed ______Name ______(Caps) Date ______

1 CORONARY HEART DISEASE RISK ASSESSMENT

Please read carefully and answer honestly the following questions regarding ones risk of Coronary Heart Disease (CHD) and Coronary Artery Disease (CAD). If you are unsure about a particular question, you should seek clarification from your GP.

PRIMARY RISK QUESTIONS YES NO

1. Are you a current cigarette smoker or one who has quit within the last 6 months?

2. Do you have a family history of diabetes, heart disease, or other cardiovascular disease under the age of fifty-five?

3. Do you have a history of high blood pressure (above 140/90)?

4. Are you taking medication for diabetes, heart disease or high blood pressure?

SECONDARY RISK QUESTIONS YES NO

5. Do you have diabetes? (Please provide details of your doctor – name and phone number and indicate the type/insulin/glucagon dependant)

6. Has your doctor ever said that you have high cholesterol?

7. Do you have any medical conditions such as arthritis, osteoporosis, heart murmur, allergies, or asthma, pain or swelling in the joints, pregnant or lactating, problems with dizziness or fainting spells, recovering from any type of injury/illness 8. Are you a male over the age of 45 or a female over the age of 55 who has previously been sedentary?

MORE THAN 1 PRIMARY RISK FACTOR OR MORE THAN 2 SECONDARY RISK FACTORS

You should delay becoming more active until you have sought medical clearance from your GP. You are to provide a letter from your GP clearing you for exercise and specifying what, if anything, they say you should not be doing. A form will be provided to you to give to your GP to ensure that you obtain all of the necessary information.

JOANNE SHREWSBURY 07894 534317 Email: [email protected]