Shameem PARQ

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Shameem PARQ

Health Questionnaire for attending Shameem.fit classes

Email *

Last Name *

First Name *

Date of Birth *

Mobile Number *

I would like to be kept up to date with information from Shameem.fit *

Yes

Any Existing Health Condiitons (please tick all relevant)

Diabetes

Epilepsey

Pain in Chest when Exercising or at Rest

Fainting / Dizzy Spells

Asthma

Surgery in the last 12 months

Any Condition or Injury which may give reason to modify exercises

Currently Pregnant

If you answered "yes" to any of the check boxes, please give further details below

By signing below (type name) i confirm that I accept that this PARQ form is not advice as to my readiness to take part in physical activity and that if I have any questions regarding my fitness to participate I will consult my GP. Assumption of Risk - I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities; which include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death. In consideration of my participation in this program, I release Moky Ltd and/or its agents from any claims, demands, and causes of action as a result of my voluntary participation and enrolment and I hereby release the Instructor and Moky Ltd from any liability now or in the future for conditions that I may obtain. *

Send me a copy of my responses.

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