PEAK FITNESS
Readiness Questionnaire and Liability Release
Regular exercise is associated with many health benefits, yet any change of activity may increase the risk of injury. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life.
Please enter your information:
First Name :
Last Name :
Address Line 1:
Address Line 2:
City :
State :
Postal Code :
Home Phone :
Cell Phone :
Work Phone :
Email :
Age :
Date of birth : MM/DD/YYYY

Please read each question carefully and answer every question honestly.
Yes  No
1) Has a physician ever said you have a heart condition and you should only do physical activity recommended by a physician?
Yes  No
2) When you do physical activity, do you feel pain in your chest?
Yes  No
3) Have you had chest pain in the past month while not doing physical activity?
Yes  No
4)Do you ever lose consciousness or lose your balance due to dizziness?
Yes  No
5) Do you have a joint or bone problem that may be made worse by a change in your physical activity?
Yes  No
6) Is a physician currently prescribing medications for your blood pressure or heart conditions?
Yes  No
7) Are you pregnant?
Yes  No
8) Do you have insulin dependent diabetes?
Yes  No
9) Are you 69 years of age or older?
Yes  No
10) Do you know of any other reason you should not exercise or increase your physical activity?
If you answered yes to any of the above questions, talk with your doctor BEFORE you become more physically active. Tell your doctor your intent to exercise and to which questions you answered yes.
If you feel that you can safely increase your level of physical activity gradually, please continue.
Please carefully read the release of Liability before proceeding.  



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I have carefully read and understand everything stated within the Release of Liability document.
If you have read and agreed to the Exercise and Testing Release of Liability then please authenticate these document with an electronic signature. By electronically signing this document you are agreeing to everything stated in the Release of Liability document. Please read the Release carefully before signing.

 
First Name :
Last Name :
Date of Birth : MM/DD/YYYY
Date of electronic signature:
 
This is an electronic representation of my full acknowledgement of the release of liability as stated above. I have read and understand the above release and accept all responsibility. Yes
I accept legal responsiblity for this signature.
Yes

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