Intake Form
















































































    • Start becoming much more physically active – start slowly and build up gradually.

    • Follow Global Physical Activity Guidelines for your age.

    • You may take part in a health and fitness appraisal.

    • If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise
      professional before engaging in this intensity of exercise.

    • If you have any further questions, contact a qualified exercise professional.



    Delay becoming more active if:

    • You have a temporary illness such as a cold or fever; it is best to wait until you feel better.

    • You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.

    • Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a qualified exercise professional before continuing with any physical activity program.













































    • It is advised that you consult a qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs.

    • You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

    • As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.

    • If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.




    • You have a temporary illness such as a cold or fever; it is best to wait until you feel better.

    • You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.

    • Your health changes - talk to your doctor or qualified exercise professional before continuing with any physical activity program.



    PARTICIPANT DECLARATION
    If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

    I have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.


    If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

    I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.