FMM - Waiver/Par-Q Template
(A Questionnaire for People Aged 15 to 69)
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.
If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.
Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO
1. Has your doctor ever said that you have a heart condition AND that 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?
3. In the past month, have you had chest pain when you were not doing physical activity?
4. Do you lose your 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 drugs (for example, water pills) for your blood pressure or heart condition?
7. Do you know of ANY OTHER REASON why you should not do physical activity?
If you answered YES to one or more questions:
If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:
Delay becoming much more active:
NOTE: If the PAR-Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section may be used for legal or administrative purposes.
"I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction."
NAME: SIGNATURE: DATE: SIGNATURE OF PARENT or GUARDIAN (for participants under the age of majority): WITNESS:
Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.
I, , release Company, (studio) andService provider _____Trainer____ from any responsibility and/or liability concerning the application, processing, and/or consequences of the service I elected to receive. I consent to have these services of my choice applied.
I release and hold __Company____ (service provider), its employees and its agents harmless against any and allliability, damage, and/or expenses arising out of or in connection with actions, claims, and/or damages resulting in personal injuries and disabilities (physical and/or psychological) that I might incur as a result of the service provided today. I understand that additional treatments may be recommended and/or necessary for maintenance.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: FMM - Waiver/Par-Q Template
Agree & Sign