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Experience
Classes
Nutrition
Wellness Services
Waiver
Medical Release
The Sound Method
Events
Gallery
SWAG
Life Life Sound
GET TO KNOW US
Our Story
Badassadors
Inquire
Inquire
Join
Request
Medical Release form and Par-Q
Name
*
First Name
Last Name
Nickname
Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Primary Doctor
Primary Doctor Phone Number
(###)
###
####
Specialist Physicians/Therapists Contact Information
List All Past Injuries Or Surgeries
List Any Current Injuries, Pains Or Physical Concerns
List All Current Medications
Please list all known allergies
*
include medication if any for known allergies
Please list any food allergies or sensitivities
*
PAR-Q
*
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
*
Do you feel pain in your chest when you do physical activity?
YES
NO
In The past month, have you had chest pain when you were not doing physical activity?
YES
NO
*
Do you lose your balance because of dizziness or do you ever lose consciousness?
YES
NO
*
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
YES
NO
*
Is your doctor currently prescribing medication for your blood pressure or heart condition?
YES
NO
*
Do you know of any reason why you should not do physical activity?
YES
NO
Health Status Questionnaire
*
Do you have any personal history of heart disease
YES
NO
*
Do you have any personal history of metabolic disease (thyroid, renal, liver)?
YES
NO
*
Do you have diabetes?
YES
NO
*
Have you experienced pain or discomfort in your chest due to blood flow deficiency?
YES
NO
*
Have you ever experienced unaccustomed or irregular shortness of breath due to physical activity?
YES
NO
*
Have you ever had problems with dizziness or fainting?
YES
NO
*
do you suffer from sleep apnea?
YES
NO
*
do you suffer from ankle edema (ankle swelling)?
YES
NO
*
Do you have an irregular heart beat?
YES
NO
*
Do you experience severe leg pain while walking?
YES
NO
*
Do you have any family history of heart or pulmonary disease?
YES
NO
*
Have you been assessed as hypertensive on more than one occasion?
YES
NO
*
Has your serum cholesterol ever been measured at greater than 240 mg/dl?
YES
NO
*
Has your HDL cholesterol ever been measured at less than 40mg/dl?
YES
NO
*
Are you a smoker and/or do you vape?
YES
NO
*
Would you characterize your lifestyle as sedentary?
YES
NO
*
Are you currently or have you ever been treated for mental illness?
YES
NO
*
Do you have a history of PTSD
YES
NO
For all yes answers to above questions:
*
Please give a brief explanation
Additional Information
*
Please list any additional health information that would be useful for our Sound Crew to be aware of and/or any reasonable consideration requests you have for participation in Be Sound classes and events
I have read and answered all the above questions accurately and honestly
*
by typing my name below I certify I understand the above questionnaire and I have not withheld information pertinent to my health and care while participating at Be Sound events
Date
*
MM
DD
YYYY
Be Sound Respects your privacy. All Medical information is strictly confidential.
Thank you!
