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Step 2 – Achieve your Breakthrough
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In the Media
Total Health Makeover Application
Preliminary Health Assessment/Par-Q/Waiver
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What is your current weight?
What is your desired weight?
What is your height?
At what age would you say you were the healthiest and felt the best?
Do you believe that you can reach your health and weight release goals?
When it comes to your weight, what is your biggest challenge?
How much time are you willing to devote to exercise? Indicate the number of days per week and the amount of time per day:
What is your fitness level?
What is your current exercise routine?
Are you prepared to give up or cut down on certain types of foods?
Has God been part of your health and weight releasing journey in the past?
On a scale of 1-10, with 1 being not important and 10 being extremely important, how important is it to get this solved - and why?
What is the #1 obstacle keeping you from solving this challenge?
Is there anyone who is supportive of your goals?
What would you like to weigh in six months?
What behaviors, beliefs or challenges do you have that could stand in the way of your achieving health goals?
What other weight loss programs have you tried in the past?
What should I know about you? In other words, how do you think? How do you reach decisions? What motivates you?
Do you pray consistently?
Rate your Faith [1 is low, 5 high]
Rate your satisfaction with your work/life balance [1 is low, 5 is high]
Rate your satisfaction with your family life [1 is low, 5 is high]
Rate your satisfaction with your finances [1 is low, 5 is high]
Rate your satisfaction with your body [1 is low, 5 is high]
Rate your satisfaction with current diet [1 is low, 5 is high]
Rate your satisfaction with your exercise routine [1 is low, 5 is high]
PAR-Q -- For most people physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide in answering these few questions. Please read them carefully and check the yes or no opposite the question if it applies to you.
Has your doctor ever said that you have a heart condition and recommended only medically approved physically activity? Yes =1 No=2
2. Do you have chest pain brought on by physical activity?Yes =1 No=2
Have you developed chest pain at rest in the past month? Yes=1 No=2
Do you lose consciousness or lose your balance as a result of dizziness? Yes=1 No=2
. Do you have a bone or joint problem that could be aggravated by physical activity? Yes=1 No=2
Is your doctor currently prescribing medication for your blood pressure or heart condition? (e.g.: diuretics or water pills) Yes=1 No=2
Are you aware, through your own experience or a doctor's advice, of any other reason against your exercising without medical approval? Yes=1 No=2
If you answered YES to one or more questions... If you have not recently done so, consult with your personal physician by telephone or in person before increasing your physical activity and/or taking a fitness test. If you answered NO to all questions... If you answered PAR-Q accurately, you have reasonable assurance of your present suitability for an exercise test. Notes: 1. This questionnaire applies only to those 15 to 69 years of age. 2. If you have a temporary illness, such as fever, or are not feeling well at this time, you may wish to postpone the proposed activity. 3. If you are pregnant, you are advised to consult with your physician before exercising. 4. If there are any changes in your status relative to the above questions, please bring this information to the immediate attention of your fitness professional. Source: Derived from 'Physical Activity Readiness Questionnaire', British Columbia Ministry of Health, Department of National Health and Welfare, Canada. Revised 1992.
Waiver- (last bit of legal stuff then you're home free) 1. As a condition of my participation in the programs of Healthy by Design, in addition to the payment of any fee or charge, I hereby waive, release, and forever discharge Healthy by Design and its employees, representatives and all others from any and all responsibilities or liability from injuries or damages resulting from my participation in any activities. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of Healthy by Design. 2. I understand that certain elements of this program can be physically demanding and that I will need to change various aspects of my lifestyle to realize the goals I have set for this program. I also understand and I am aware that strength, flexibility, and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also understand that fitness activities may involve the risk of injury, and that I am voluntarily participating in these activities and using equipment with the knowledge of the potential dangers involved. I hereby agree to expressly assume and accept any and all risks of injury. 3. I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or illness that would prevent my participation or use of equipment or machinery except as hereinafter stated. I acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with my physician as to physical activity, exercise, and use of exercise and training equipment so that I might have his/her recommendations concerning these fitness activities and equipment use. I acknowledge that I have either had a physical examination and been given my physician’s permission to participate, or that I have decided to participate in activity without the approval of my physician and do hereby assume all responsibility for my participation and activities, and utilization of equipment in my activities. 4. I declare that I have read, understood and agree to the contents of this WAIVER in its entirety by clicking the submit button below. Please be sure all areas are completed before pressing 'Submit'. Incomplete forms will produce an error and entries will be lost. Hint: Answers can be typed in a word processing program or notepad first, then pasted into the form.
I agree to the above terms and conditions- please check before exiting
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