PARTICIPANT INFORMATION SHEET

First Name:

Last Name:

Address:

Street

City

State

zipcode

Primary Phone:

Alternate Phone:

E-mail Address:

Date of Birth

Age:

Current Height:

Current Weight:

Emergency Contact & Phone Number:

Class/es your are interested in attending:

What is your current occupation:

Does your occupation require extended periods of sitting? Yes No

Does your occupation require you to wear shoes with a heel? Yes No

Does your occupation frequently cause you anxiety or mental stress? Yes No

Do you partake in any recreational activities (e.g., golf, tennis, skiing, bowling)? Yes No

If so, please describe.

Do you belong to a gym? Yes No

If so, what gym

and what do you do there (e.g., classes, cardio, drink smoothies)?

What, if any, are your current hobbies (e.g., reading, gardening, working on cars, playing an instrument)?

What are your current fitness goals? If weight loss is a goal, what do you believe your ideal weight should be? When was the last time you were at that weight?

How often do you currently participate in exercise?

and in what form?

What is your favorite type of exercise and your least favorite (and why)?

my favorite type of exercise is

my least favorite is

, because

Did you participate in sports in high school or college? Yes No

If so, what sports?

If weight loss (or gain) is one of your goals and you are comfortable sharing the information, please maintain a full and honest (i.e., representative) food diary for at least two complete days prior to our next meeting. Please include every bite and taste (including all beverages and water).

(Feel free to email your completed food log to java@javafitness.com or bring to your first class/session.)

Liability Waiver:

, (1) understand that there are risks inherent in any type of physical activity; (2) represent that I am in good physical condition and have no disabilities, diseases, illnesses or other conditions that could prevent me from participating in an exercise program without injuring myself or impairing my health; and (3) represent that I have consulted a physician who has approved my participation in an exercise program of this nature. Should injury occur while participating in this class, I agree to hold Java Fitness, LLC and its employees harmless for any such injuries.

________________________________________

Signature (to be signed before class)

________________________________

Date

Thank you, your survey was received. You have just filled out the form.
We will contact you as soon as possible,
ciao!

PARTICIPANT INFORMATION SHEET

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

New Content

Most Read Content