Physical Fitness Readiness Inventory

For most people, physical activity does not pose a problem or hazard.  The Par-Q (Physical Activity Questionnaire)* is concerned with identifying individuals for whom physical activity may be contraindicated or who may require medical advice before participation.  Please supply the following information concerning yourself.  If you answer yes, please explain in the space provided.  This information will be held in the strictest confidence.  Please print all information.

Name 

Furman Program

Address

City, State, Zip

Phone

Date of birth   Age    Gender 

    Yes     No

1.      Has your physician ever stated you have heart trouble? 

2.      Do you frequently suffer chest pains? 

3.      Do you often feel faint or have dizzy spells?  

4.     Has a physician ever stated that you have a bone or joint problem such as arthritis that may be aggravated or made worse
                       by exercise? 

5.     Is there a physical reason not mentioned here as to why you should not follow an activity program?  

6.     Are you taking ANY prescribed or over-the-counter medications?  Please list 

7.     Comment on any other information (medical, physical, orthopedic, etc.) concerning your overall health and medical
                       history relative to physical activity. 

In a maximal hour of fitness, approximately a 2.5 in 10,000 chance of adverse symptoms exist with the odds of a more serious event approximately 1 in 10,000.   I understand that my questions will be fully answered.

Printed Name                                                                                       Signature                                                              Date

*British Columbia Dept. of Health

American College of Sports Medicine

HERMAN W. LAY PHYSICAL ACTIVITIES CENTER

INFORMED CONSENT FOR PARTICIPATION IN AN EXERCISE PROGRAM

Please read and sign below:

1.         EXPLANATION OF THE PROGRAM RISKS

            I, the undersigned, being of sound mind, understand that Furman University offers membership for the purpose of exercise at the Herman W. Lay Physical Activities Center.  I consent to voluntarily engage in an acceptable plan of personal fitness training.  I also give consent to be placed in personal fitness training program activities that are recommended to me based upon my cardiorespiratory (heart and lungs) and muscular fitness for improvement of my general health and wellbeing.  I understand I will be given guidelines regarding the amount and kind of exercises I should do, and it is my responsibility to follow the appropriate guidelines.  If I am taking prescribed medications, I have already so informed the staff and further agree to so inform them promptly of any changes my doctor or I make with regard to the use of these during exercise.  I will be given the opportunity for periodic assessment and evaluation after the start of my membership.  In a maximal bout of fitness, approximately 2.5 in 10,000 chances of adverse symptoms exist with the odds of a more serious event such as a heart attack approximately 1 in 10,000.

            I have been informed that during my participation in any exercise program, I should cease activity if symptoms such as fatigue, shortness of breath, chest discomfort, or similar occurrences appear.  I also understand that it is my obligation to inform the personnel on duty in the Physical Activities Center of my symptoms.  I hereby state that I have been so advised and agree to inform the personnel of my symptoms, if any, develop.  I also understand that the personnel may reduce or stop my activity program when or if any symptoms indicate that this should be done for my safety and benefit.

2.         BENEFITS TO BE EXPECTED

            Participation in the exercise program may or may not benefit me directly in any way.  Regular adherence to a program should increase your overall physical fitness and well being; however, other factors such as eating habits, stress and activity outside of this program may also influence the possible benefits.

3.         INQUIRIES

            Any questions about your exercise program are welcome.  If I have doubts or questions, I can ask Physical Activities Center personnel or the supervisor for further explanations.

4.         FREEDOM OF CONSENT

            Membership in the Herman W. Lay Physical Activities Center is voluntary.  I am free to deny consent if I so desire, both now and at any point during the course of my membership.

            I have read this form and understand the program in which I will be engaged.  I consent to participate in this program.  In addition, I agree to inform the instructor or the director of any future medical conditions or medications, which may affect participation in physical activity.  Furthermore, I understand that I may not hold Furman University or any of its employees or students liable for any injury or accident which may occur during or as a result of the membership in the Herman W. Lay Physical Activities Center.  Lastly, I give the staff of the Herman W. Lay Physical Activities Center permission to administer basic first aid in the event of the emergency.

Printed Name                                         Signature (Signature of parent of under 18 years of age)                       Date