JinFit Par Q Question Title * 1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended be a doctor? Yes No Question Title * 2. Do you ever experience chest pain during physical activity Yes No Question Title * 3. Do you have a history of epilepsy or seizures Yes No Question Title * 4. Do you have a bone or joint problem that could be made worse be change in physical activity participation Yes No Question Title * 5. Do you have uncontrolled asthma (i.e asthma that is not easily controlled by an inhaler)? Yes No Question Title * 6. Do you know of any other reason why you should not undergo physical activity? This might included diabetes, a recent injury, or serious illness. Question Title * 7. If you have answered yes to any of the questions above please gives more information Question Title * 8. In signing this form, I, affirm that I have read this form in its entirety and I have answered the questions accurately and the best of my knowledge. I understand that I am responsible for monitoring myself throughout any activity, should any unusual symptoms occur, would ease participation and inform the instructor. If medical clearance must be obtained before my participation in an exercise session. I agree to contact my physician and obtain written permission prior to the commencement of the exercise activity, and that the permission be given to the instructor. Name Address Address 2 Town Postal Code Email Address Phone Number Question Title * 9. Name of Emergancy Contact and Number Done