Physical Activity Readiness Questionnaire (PAR-Q)
YES / NO / 1) Has your doctor ever said you have a heart condition and you should only do physical
activity recommended by a doctor?
YES / NO / 2) Do you feel pain in your chest when you do physical activity?
YES / NO / 3) In the past month, have you had chest pain when you were NOT doing physical
activity?
YES / NO / 4) Do you ever lose consciousness or do you lose your balance because of dizziness?
YES / NO / 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?
YES / NO / 6) Is your doctor currently prescribing drugs (for example, water pills) for your blood
pressure or heart condition?
YES / NO / 7) Are you pregnant?
YES / NO / 8) Do you know of any other reason you should not exercise or Increase your physical
activity? If yes, please list below.
______
If you answered Yes to any of the above questions, please complete the Physician’s Statement and Clearance
Form prior to being scheduled for a fitness assessment or personal training. If you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually.
If your health changes so you then answer yes to any of the above questions, seek guidance from a physician. I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction.
Name:
Signature (to sign during FA):
Date:
Confidentiality Notice
This document contains confidential information intended only for the use of the Campus Recreation Center and the individual member.
Privacy Statement
You are entitled to be informed about the information UTSA collects about you. Under Sections 552.021 and 552.023 of the Texas Government code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government code, you are entitled to have UTSA correct information about you that is held by us and that is incorrect, in accordance with the procedures set forth in the University of Texas System Business Procedures Memorandum 32. The information that UTSA collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time.
Fitness Assessment & Personal Training Liability Waiver
I agree to allow the UTSA Fitness & Wellness Staff to assess my level of fitness and/or design an exercise program for me to enhance my health & fitness goals. I have discussed my health and fitness goals with them and have provided them all relevant and necessary information about myself, including my health and physical well-being, to allow them to accurately assess my level of fitness and develop a safe and effective program for me.
I understand that in developing an exercise program for me, UTSA Fitness & Wellness Staff are not guaranteeing any specific results.
I understand that changes in my physical activity may affect my physical well-being. I accept all risk to my health, including injury or death, that may result from my participation in this Fitness Assessment and/or the program designed. I hereby release UTSA, its governing board, officers, representatives, employees and agents, from any and all liability for any and all claims and causes of action for loss of or damage to my property and for any and all illness and injury to my person, including my death, that may occur as a result of my participation in this Fitness Assessment and/or the program designed.
I further agree to indemnify and hold harmless UTSA, its governing board, officers, representatives, employees and agents from liability for the injury or death of any person(s) and damage to property that may arise, in whole or in part, from my negligent or intentional act or omission while participating in this Fitness Assessment and/or the program designed, whether CONTRIBUTED TO OR CAUSED BY ANY negligence of UTSA, its governing board, officers, employees or representatives, or otherwise.
I understand that this exercise program does not replace the expert advice or medical treatment of my own private doctor. I acknowledge that the Fitness & Wellness Staff are not medical doctors. I understand that their assessment of my physical well-being and the program they develop for me will be based upon the information I provide to them. I have given the Fitness & Wellness Staff all necessary information about myself to prevent any possible complications.
Participant Name: Banner ID:
Signature (To sign during FA): Date: ______
Phone Number: ______Email: ______
Availability
Preferred Trainer: ______
I am available on the following days/times:
Monday: ______
Tuesday: ______
Wednesday: ______
Thursday: ______
Friday: ______
Saturday: ______
Sunday: ______
You will be contacted by your Personal Trainer within one week.
We look forward to working with you