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Health Questionnaire

Health & Fitness History

Step 1 of 6

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  • For most people, physical activity should not pose any problem or hazard. This questionnaire has been designed to identify those people for whom physical activity might be inappropriate, or those who should have medical advice concerning the type of activity most suitable for them. If you answer “yes” to any of the questions below, consult with your doctor before starting any exercise program.
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  • General History

  • General History, cont.

  • Family History (Immediate family only)

    >
  • Smoking History

  • Pulmonary History

  • Have you ever experienced any of the following:

  • Medications

  • MedicationCondition 
  • MedicationCondition 
  • Nutritional History

  • Name of DietDatesWeight LostHow Long Maintained Weight Loss? 
  • Nutritional History

  • Orthopedic History

    Describe any present or past musculoskeletal or joint conditions you have (i.e muscle pulls, sprains, fractures, surgery, pain, arthritis, or any other general discomfort):
  • Women’s Health

  • Cardiovascular History

  • Lifestyle

  • I understand the nature and purpose of the Physical Activity Readiness Questionnaire and am aware that any strenuous physical activity involves risks. Accordingly, I release, discharge, absolve, and hold harmless Destiny Management, their agents, instructors and employees, for any and all liability arising from any accident, injury, or loss sustained by me as a result of activities at or present in the Facility. I declare to the best of my knowledge my answers are true, correct, and complete.
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  • INFORMED CONSENT FOR A HEALTH RELATED EXERCISE TEST

    1. Explana􀆟on of the Exercise Test
    You will perform a battery of fitness tests that may include a cardiovascular test on a cycle ergometer or a bench step test, a sit & reach test for flexibility, a push‐up test and a sit‐up test for muscular endurance, and a body compositions test which is analyzed by taking several skinfold measures to calculate the percentage of body fat along with circumference measurements. For the cardiovascular test, the exercise intensity will begin at a level you can easily maintain and will be advanced in stages depending on your fitness level. For the other tests, you will be going to failure. We may stop the tests at any 􀆟me because of signs of fa􀆟gue or you may stop when you wish because of personal feelings of fatigue or discomfort.
    2. Risks and Discomforts
    There exists the possibility of certain changes occurring during the tests. They include abnormal blood pressure, fainting, disorder of heart beat, and, in rare instances, heart attack, stroke, or death. Every effort will be made to minimize these risks by evaluation of preliminary information relating to your health and fitness and by observations during the tests. Emergency equipment and trained personnel are available to deal with unusual situations that may arise.
    3. Responsibilibies of the Parcicipant
    Informa􀆟on you possess about your health status or previous experiences of unusual feelings with physical effort may affect the safety and value of your exercise tests. Your prompt reporting of feelings with effort during the exercise tests itself are also of great importance. You are responsible to fully disclose such information when requested by the testing staff.
    4. Benefits to be Expected
    The results obtained from the exercise tests may assist in diagnosis of your illness or in evaluating what type of physical activities you might do with low risk of harm.
    5. Inquiries
    Any questions about the procedures used in the exercise tests or in the estimation of functional capacity are encouraged. If you have any doubts or questions, please ask us for further explanations.
    7. Freedom of Consent
    Your permission to perform these exercise tests are voluntary. You are free to deny consent or stop the test at any point if you so desire.
    I have read this form and I understand the test procedures that I will perform. I consent to participate in the tests.
  • MM slash DD slash YYYY
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  • Services
    • Personal Training
    • Nutrition
    • Yoga
    • Massage
    • Corporate Wellness
    • Conquer Diabetes
  • Products
    • Books
    • Gift Shop
    • Healing Hands by Ashley (FREE shipping on orders over $150)
    • Programs/Gift Certificates
    • Supplements (FREE shipping on orders over $150)
  • About
    • Terry Linde
    • Ashley Dykstra
    • Liz Wyosnick
  • FAQs
  • Blog
  • Member Area
    • Health Questionnaire
    • Liability Waiver
    • Services Agreement
  • Contact Us
  • Services
    • Personal Training
    • Nutrition
    • Yoga
    • Massage
    • Corporate Wellness
    • Conquer Diabetes
  • Products
    • Books
    • Gift Shop
    • Healing Hands by Ashley (FREE shipping on orders over $150)
    • Programs/Gift Certificates
    • Supplements (FREE shipping on orders over $150)
  • About
    • Terry Linde
    • Ashley Dykstra
    • Liz Wyosnick
  • FAQs
  • Blog
  • Member Area
    • Health Questionnaire
    • Liability Waiver
    • Services Agreement
  • Contact Us
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