PRE-ACTIVITY QUESTIONNAIRE

We recommend that anyone engaging in a new fitness regime consult their doctor before doing so. 

NAME *
NAME
DATE OF BIRTH *
DATE OF BIRTH
1. Has a doctor ever said you have a heart condition, recommending only medically supervised activity? *
2. Do you have chest pain brought on by physical activity? *
3. Have you developed chest pain in the last month? *
4. Have you on one or more occasion lost consciousness or fallen over as a result of dizziness? *
5. Do you have a bone or joint problem that could be aggravated by the proposed physical activity? *
6. Has a doctor ever recommended medication for your blood pressure or a heart condition? *
7. Do you suffer from epilepsy or seizures brought on by flashing lights? *
8. Are you aware, through your own experience or a doctor’s advice, of any other physical reason that would prohibit you from exercising without medical supervision? *
I hereby state that I have read, understood and answered honestly the questions above and that any statements made by me in answering this Pre-Activity Questionnaire are true and accurate. I also state that I wish to participate in activities which includes high intensity cardiovascular/resistance training. I understand that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise given my knowledge of my health and taking into account any medical advice I have received. I also voluntarily indemnify, release from liability, and hold harmless BARE Fitness Centre, the BARE Coaches, and the facility for any accident, injury, illness, death, loss, damage to person or property, or other consequences suffered by me or any other person arising or resulting directly or indirectly from my participation in BARE’s activities. *