155 Military Road, Lancaster, Ontario K0C-1N0

Click here to Print

1 Client + 1 Trainer

Prepaid (Paid in Full)

  • Client's Information

  • -
  • -
  • Health Questionnaire (PAR-Q)

    A questionnaire for people aged 16 to 69.
  • Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.

    If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.

    Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

  • Yes No
    Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
    Do you feel pain in your chest when you do physical activity?
    In the past month, have you had chest pain when you were not doing physical activity?
    Do you lose balance because of dizziness or do you ever lose consciousness?
    Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
    Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
    Do you know of any other reason why you should not do physical activity?
  • If you answered YES to one or more questions.

    Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.

    • You may be able to do any activity you want — as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

    • Find out which community programs are safe and helpful for you

    If you answered NO to all questions.

    If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:

    • Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.

    • Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.


    • If you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better; or

    • If you are or may be pregnant – talk to your doctor before you start becoming more active

    PLEASE NOTE: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional.

    Ask whether you should change your physical activity plan.

    Informed Use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity.

    No changes permitted. You are encouraged to photocopy the PAR-Q but only if you use the entire form.

    NOTE: If the PAR-Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section may be used for legal or administrative purposes.

    "I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction."

  • Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.

  • TRAINING - Agreement, Terms & Conditions


    Congratulations on your decision to participate in an exercise program! With the help of your personal trainer, you greatly improve your ability to accomplish your training goals faster, safer, and with maximum benefits. The details of these training sessions can be used for a lifetime.

    In order to maximize progress, it will be necessary for you to follow program guidelines during supervised and (if applicable) unsupervised training days. Remember, exercise and healthy eating are EQUALLY important!

    During your exercise program, every effort will be made to assure your safety. However, as with any exercise program, there are risks, including increased heart stress and the chance of musculoskeletal injuries. In volunteering for this program, you agree to assume responsibility for these risks and waive any possibility for personal damage. You also agree that, to your knowledge, you have no limiting physical conditions or disability that would preclude an exercise program.

    By signing below, you accept full responsibility for your own health and well-being AND you acknowledge an understanding that no responsibility is assumed by the leaders of the program.

    It is recommended that all program participants work with their personal trainer three (3) times per week. However, due to scheduling conflicts and financial considerations, a combination of supervised and unsupervised workouts is possible.


    Personal training sessions that are not rescheduled or canceled 24 hours in advance will result in forfeiture of the session and a loss of the financial investment at the rate of one session.

    Clients arriving late will receive the remaining scheduled session time, unless other arrangements have been previously made with the trainer.

    The expiration policy requires completion of all personal training sessions within 1 Year from the Personal Training Start Date. Personal training sessions are void after this time period and Platinum Fitness & Supplements will debit the above mentioned card for any remaining balance due and payable.

    No personal training refunds will be issued for any reason, including but not limited to relocation, illness, and unused sessions.

    I have read and agree with all of the above.

  • GYM / TRAINING - Parental Consent

    Required for all members under the age of 18.

    In consideration of participation in exercise activities, I agree, on behalf of the above named child, his/her heirs and representative, to fully and forever release, Platinum Fitness & Supplements, its officers, volunteers, agents and employees from any and all liability, claims, demands, damages, actions, of causes of action, whatsoever arising out of a or related to belonging to my child or me, related to the exercise activities, regardless of cause. This release covers everything that happens from the time my child arrives at Platinum Fitness & Supplements until he/she leaves.


    To the best of my knowledge, the above named child can fully participate in exercise activities. I am aware of the risks and hazards connected with exercise activities and my child hereby elects to voluntarily participate in the exercise activities, knowing that the exercises and equipment may be dangerous to my child. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury that may be sustained by my child or any loss or damage to property owned by me or my child, as a result of being engaged in exercise activities at Platinum Fitness & Supplements, regardless of who caused the incident.


    It is my express intent that this release and hold harmless agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs assigned and personal representatives, if I am not alive, shall be deemed as a release, waiver, discharge and covenant not to sue Platinum Fitness & Supplements. I hereby further agree that this waiver of liability and hold harmless agreement shall be construed in accordance with the laws of the province of Ontario.


    I understand that Platinum Fitness & Supplements will not be responsible for any medical costs associated with any injury my child may sustain.


    My child and I further agree to become familiar with the regulations of Platinum Fitness & Supplements concerning participant conduct and not to violate said rules of any directive or instruction made by the person or persons in charge of the exercise facility.


    I have reviewed this Agreement and am aware of the risks involved in participating in the exercise activities and the possible injuries that may occur. My child freely and voluntarily agrees to participate in the exercise activities. In signing this release, I represent that I understand this Agreement and sign voluntarily as an act of my own free will. Platinum Fitness & Supplements has not made any oral representations, statements, or inducements, apart from this Agreement. I am at least eighteen (18) years of age and fully competent to execute this Agreement. Also, I understand that all rules and regulations for Platinum Fitness & Supplements will be enforced and any violation by my child may result in a call to me with a possible request to come and pick up my child.

  • -

  • - -
  • Should be Empty: