If you are between the age of 15 and 69 this PAR-Q is used to assess whether or not you should check with your doctor before making a change to your physical activity levels. If you are over 69 years old and not used to being active, speak to your doctor. Please read the questions carefully and check the correct box.
Do you have a heart condition or have been told by a doctor not to exercise?(Required)
Have you ever had chest pain when exercising?(Required)
ln the past month have you had chest pain when not exercising?(Required)
Do you lose your balance from dizziness, or do you ever lose consciousness?(Required)
Do you have any bone or joint problems?(Required)
Are you currently on any medication?(Required)
Are you currently diagnosed with any health issues?(Required)
(for example - high/low blood pressure, diabetes, heart conditions or arthritis)
Do you take performance enhancing or recreational drugs?(Required)
Do you drink?(Required)
Do you smoke?(Required)

I have read, understood, and accurately answered this questionnaire. I confirm that I am voluntarily engaging in physical activity, and my participation involves a risk of injury in any facility with LEVEL10LIFE. if I have answered yes to 1 or more of the questions, I have sought medical advice and my GP has agreed I may exercise.

Informed Consent Agreement

MM slash DD slash YYYY

Program Objectives

I understand that my physical fitness program is individually tailored to meet the goals and objectives agreed upon by my coach and myself. I understand, however, that my coach cannot guarantee that I will accomplish the goals that are established. Description of the Exercise Program I understand that my exercise program will involve participation in a number of types of fitness activities. These activities will vary depending upon my established objectives, but will probably include: 1) Aerobic activities including, but not limited to, the use of treadmills, stationary spin bicycles, rope machines, arm cycle ergometers, rowing machines, running, agility drills, Jacobs Ladder, sled push/pulls, circuit training, and step exercises. 2) Muscular endurance and strength building exercises including, but not limited to, the use of free weights, kettle bells, medicine balls, exercise bands, cable machines, ropes and other exercise apparatus. 3) Other activities selected by my personal trainer and agreed upon by me. 4) Selected physical fitness and body composition tests.

Description of Potential Risks

My coach has explained that no exercise program is without inherent risks and that, regardless of the care taken by my coach, he (or she) cannot guarantee my personal safety. For example, when one induces cardiovascular stress through activity, injuries can range from occasional minor injury (e.g. pulled muscles, muscle soreness) to infrequent serious injury (e.g. heart attack, stroke, or other cardiovascular accidents) to the very rare catastrophic incident (e.g. death, paralysis). Likewise, I know that engaging in muscular endurance, strength building, and other fitness activities occasionally results in minor injuries (e.g. bruises, musculo-skeletal strains and sprains), infrequently, more serious injuries (e.g. muscle tears, herniated disks, torn rotator cuffs), and very rarely, catastrophic injury (e.g. death, paralysis). I realize that when participating in any exercises or conditioning activity, there is always a possibility that minor injuries, major injuries, or catastrophic injury/death may occur. I understand that a regular exercise program has been shown to have definite benefits to general health and well-being. I know that some of the physiological benefits of a regular exercise program can include loss of weight, reduction of body fat, improvement of blood lipids, lowering of blood pressure, improvement in cardiovascular function, reduction in risk of heart disease, improved strength and muscular endurance, improved posture, and improved flexibility. I further understand that regular exercise can have psychological benefits, often improving one’s outlook as well as relieving tension and stress.

Client Responsibilities

I understand that it is my responsibility to: 1) Take seriously and to the best of my ability I will comply with all of the program components in an effort to assist in the achievement of my goals. 2) Inform my coach if there are any activities with which I do not feel comfortable. 3) Cease exercise and report promptly any unusual feelings (e.g. chest discomfort, nausea, difficulty breathing, apparent injury) during the exercise program.

Medical Consent

I understand that my training sessions are not medically supervised and that my training program has been developed for healthy people with no prohibitive medical conditions or risks, either physical or psychological. If necessary, the sessions will be modified to accommodate specific injuries or conditions diagnosed by a physician with that physicians’ written medical consent to participate in the program. In addition to the terms above, I represent that I am in good physical condition and have no medical reason or impairment that might prevent me from participation in the program. I will fully disclose any health issues or medications that are relevant to participation in a strenuous exercise program. If my physical or mental condition presents limitations to participation, I will receive a signed Physician Release Form. This form represents my physician’s approval to participate in the training sessions. Any specific allergies, reactions and/or contraindication to medications involved with any supplementation will be my responsibility and the responsibility of my prescribing medical doctor.

Client Acknowledgements

In agreeing to this exercise program, I, the client: • Acknowledge that my participation is voluntary. • Understand the potential risks involved in the exercise program and believe that the potential benefits outweigh those risks. • Give consent to certain physical touching or visual assessing that may be necessary to ensure proper technique and body alignment. • Understand that the achievement of health or fitness goals cannot be guaranteed. • Have had a voice in planning and approving the activities selected for my exercise program. • Have been able to ask questions regarding any concerns I might have and have had those questions answered to my satisfaction. • Am in good physical condition, have no impairment that might prevent my participation in such activities, and have been advised to consult a physician prior to beginning this program. • Have been advised to cease exercise immediately if I experience unusual discomfort and feel the need to stop.
By signing above on the date first mentioned above, I acknowledge and agree that I have read the foregoing and know of the nature of the activities and I agree to all the terms of this Agreement.


  • DD slash MM slash YYYY
    1-Very unsure > 10-Very confident
    1-Very unsure > 10-Very confident
    1-New to the gym / training > 10-Several years of training experience
    1-Unconfident > 10-Very confident