HOLLYWOOD FIT BODY BOOT CAMP PHYSICAL ACTIVITY READINESS Physical activity should not be hazardous for most people. The PAR-Q has been designed to identify those individuals who should seek medical attentions prior to beginning a physical fitness program. Please answer all questions accurately and honestly to allow us to fully determine your individual needs. Body Fat %________ Date_____________ LAST NAME_________________________ FIRST NAME_______________________ ADDRESS______________________ CITY___________ STATE_____ ZIP_________ CELL PHONE#________________ EMAIL ADDRESS__________________________ AGE______________ HEIGHT________________WEIGHT______________________ 1. Do you have high cholesterol? 2. Has your doctor ever said that you have heart trouble? 3. Has your doctor ever told you that you have a bone or joint problem (such as arthritis) that has been or may be exacerbated by physical activity? 4. Has your doctor ever told you that your blood pressure was too high? 5. Are you over 65 years of age and not accustomed to vigorous exercise? 6. Is there any reason, not mentioned thus far, that would not allow you to participate in a physical fitness program? YES _____ _____ _____ _____ _____ _____ NO _____ _____ _____ _____ _____ _____ BUYER ACKNOWLEDGMENT AND ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF HOLLYWOOD FIT BODY BOOT CAMP BUYER ACKNOWLEDGES THESE PHYSICAL ACTIVITIES INVOLVES THE INHERENT RISK OF PHYSICAL INJURIES OR OTHER DAMAGES, INCUDING, BUT NOT LIMITED TO, HEART ATTACKS, MUSCLE STRAINS, PULLS OR TEARS, BROKEN BONES, SHIN SPLINTS, HEART PROSTRATION, KNEE/LOWER BACK/FOOT INJURIES AND ANY OTHER ILLNESS, SORENESS, OR INJURY HOWEVER CAUSED, OCCURRING DURING OR AFTER BUYER’S PARTICIPATION IN THE PHYSICAL ACTIVITES. BUYER FURTHER ACKNOWLEDGES THAT SUCH RISKS INCLUDE, BUT AR NOT LIMITED TO, INJURIES CAUSED BY THE NEGLIGENCE OF AN INSTRUCTOR OR OTHER PERSON, DEFECTIVE OR IMPROPERLY USED EQUIPMENT, OVER-EXERTION OF A BUYER, SLIP AND FALL BY BUYER, OR AN UNKNOWN HEALTH PROBLEM OF BUYER. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY INVOLVED WITH PARTICIPATION IN THE PHYSICAL ACTIVITIES, BUYER AFFIRMS THAT BUYER IS IN GOOD PHYSICAL CONDITION AND DOES NOT SUFFER FROM ANY DISABILITY THAT WOULD PREVENT OR LIMIT PARTICIPATION IN THE PHYISCAL ACTIVITIES. BUYER ACKNOWLEDGES PARTICIPATION WILL BE PHYSICALLY AND MENTALLY CHALLENGING, AND BUYER AGREES THAT IT IS THE RESPONSIBILITY OF BUYER TO SEEK COMPETENT MEDICAL OR OTHER PROFESSIONAL ADVICE, REGARDING ANY CONCERNS OR QUESTIONS INVOLVED WITH THE ABILITY OF BUYER TO TAKE PART IN HOLLYWOOD FIT BODY BOOT CAMP PHYSICAL ACTIVITIES. BY SIGNING THIS AGREEMENT, BUYER ASSERTS THAT HE OR SHE IS CAPABLE OF PARTICIPATING IN THE PHYSICAL ACTIVITIES. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY FOR NOT EXCEEDING HIS OR HER PHYSICAL LIMITS. INITIAL________ HOLLYWOOD FIT BODY BOOT CAMP The following information will be treated as privileged information: 1. Do you ever feel weak, fatigued, or sluggish? 2. How many meals do you eat each day? _____________ 3. Do you know how many calories you eat in a day? 4. Do you eat breakfast? 5. Are you taking supplements? YES _____ _____ _____ NO _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ most (i.e. vitamins, amino acids, protein shakes, etc.) 6. Do you crave sugary foods? 7. Do you need several cups of coffee to keep you going throughout the day? 8. Do you often experience digestive difficulties? 9. Proper nutrition can increase the body’s ability to enhance physical and mental performance by up to 80%. Do you feel that a properly structured nutrition and exercise program would benefit you? 10. How long have you been exercising? ________________ 11. Have you reached and maintained your goals? 12. Are you happy with the way you look and your health? 13. On a scale of 1 to 10, how serious are you about achieving your goals? least 1 2 3 4 5 6 7 8 9 10 Please list your desired fitness goals: Desired Body Fat: _________ Desired Weight: _________ Desired Waist Size: _________ Desired Dress or Pant Size: _________ I plan to exercise _________ times a week I am looking forward to getting fit and achieving results because when I do I’ll finally be able to... _____ _____ _____ _____ _____ _____ _____