Name *

First Name

Last Name

Physical Activity Readiness Questionnaire (PAR-Q): Read the following 7 questions and check Yes or No. If you answer Yes to one or more questions, a medical clearance form from your physician will be required before you can participate in the Boot Camp sessions. 1) Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

2) Do you feel pain in your chest when you do physical activity? * *

Yes

No

3) In the past month, have you had chest pain when you were not doing physical activity?

Yes

No

4) Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

5) Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? *

Yes

No

6) Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes

No

7) Do you know of any other reason why you should not do physical activity? *

Yes

No

Please indicate with a check mark if you have experienced any of the following, please select "NONE" if none apply: *

Heart Disease

Pulmonary Disease

Metabolic Disease

Family History of Heart Disease

High Blood Pressure

High Cholesterol

Smoking (within past year)

Asthma

Sedentary Lifestyle

Chest Pain

Dizziness

Shortness of Breath

Irregular or Accelerated Heart Rate

Osteoporosis Arthritis or Joint Pain

Back Pain or Spine Disorder

Musculoskeletal Pain or Injury

Hernia

Surgery

Hypoglycemia

G.I. Disorder

High Triglycerides

Cancer

Prenatal or Postnatal

Anemia

NONE

Are you interested in a 30 minute one on one "success consultation" with Saara to discuss your barriers to a healthy life? We also spend this time figuring out how to get you on your best path to success ($70 value). Please indicate if you are interested below.

Yes

No