Physical Activity Readiness Questionnaire (PAR-Q) and Health History Questionnaire (HHQ)



This Agreement is entered into between  Excel Rocktown and the undersigned (“Client”). The provision of coaching services by Excel Rocktown to Client, and Client’s use of any premises, facilities or equipment are contingent upon this Agreement.


You agree that if you engage in any physical exercise or activity, you do so at your own risk and assume the risk of any and all injury and/or damage you may suffer, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from using any premises or facility, or using any equipment, whether provided to you by Excel Rocktown or otherwise, including injuries or damages arising out of the negligence of Excel Rocktown, whether active or passive, or any of Excel Rocktown’s affiliates, employees, agents, representatives, successors, and assigns.

Your assumption of risk includes, but is not limited to, your use of any exercise equipment (mechanical or otherwise), sports fields, roads/trails (public or private), courts, or other areas, locker rooms, sidewalks, open bodies of water, swimming pools, swim flumes, parking lots, stairs, whirlpools, saunas, steam rooms, or other general areas of any facilities, or any equipment. You assume the risk of your participation in any activity, class, program, instruction, or event, including but not limited to weightlifting, walking, running (indoor or outdoor), cycling (indoor or outdoor), swimming (indoor or outdoor) or cross training activities. You agree that you are voluntarily participating in the aforementioned activities and assume all risk of injury, illness, damage, or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property, whether arising out of the negligence of Excel Rocktown or otherwise.



You agree on behalf of yourself (and all your personal representatives, heirs, executors, administrators, agents, and assigns) to release and discharge Excel Rocktown (and Coach’s affiliates, related entities, employees, agents, representatives, successors, and assigns) from any and all claims or causes of action (known or unknown) arising out of the negligence of Coach, whether active or passive, or any of Excel Rocktown’s affiliates, employees, agents, representatives, successors, and assigns.

This waiver and release of liability includes, without limitation, injuries which may occur as a result of (a) your use of any exercise equipment or facilities which may malfunction or break, (b) improper maintenance of any exercise equipment, premises or facilities, (c) negligent instruction or supervision, including coaching, (d) traveling to or from coaching session(s).


By execution of this agreement, you hereby agree to indemnify and hold harmless Excel Rocktown from any loss, liability, damage, or cost Excel Rocktown  may incur due to the provision of coaching by Excel Rocktown to you.


You expressly agree that the foregoing release, waiver, assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by the law in the State of Virginia and that if any portion thereof is held invalid, it is agreed that the balance of the waiver will continue in full legal force and effect. You acknowledge that Excel Rocktown offers a service to their clients encompassing the entire recreational, sporting and/or fitness spectrum. This release is not intended as an attempted release of claims of gross negligence or intentional acts.

You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability, express assumption of risk and indemnity agreement. You are aware and agree that by executing this waiver and release, you are giving up your right to bring a legal action or assert a claim against Excel Rocktown for coach’s negligence, or for any defective product used while receiving coaching services from Excel Rocktown. You have read and voluntarily signed the waiver and release and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.



Please answer each question honestly, use common sense as your guide.

  • 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 your balance because of dizziness or do you ever lose consciousness?
  • Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse 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 of the above questions, talk with your doctor BEFORE you start becoming much more physically active or BEFORE you start a coaching program. Tell your doctor about the PAR-Q and which questions you answered YES to.

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.

If you answered NO to all the PAR-Q questions, you can be reasonably sure that you can start becoming more physically active and start a coaching program. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 140/90, talk with your doctor before you start becoming more physically active or starting a coaching program.


PAR-Q developed by the Canadian Society for Exercise Physiology


I have answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factor in the development of my coaching program. I understand that certain medical or physical conditions which are known to me, but that I do not disclose to my coach may result in serious injury to me. If any of the above conditions change, I will immediately inform my coach of those changes. I, knowingly and willingly, assume all risks of injury resulting  from failure to disclose accurate, complete, and updated information in accordance with the attached questionnaire.


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