Functional EMS Training PAR-Q | The WELL TRAINED Way

First name

Last name

Email

Phone

Gender

Male

Female

Other

Birthday

Month

Day

Year

Height

Weight

List all of your fitness and health goals

Is there a time limit of which you need or would like to achieve the goals you listed above?

Have you ever been told by a medical professional that you have a heart problem and/or that you should avoid physical activity?

Yes

No

Do you feel pain of discomfort in your chest during physical activity?

Yes

No

Do you experience loss of balance due to dizziness or vertigo?

Yes

No

Have you ever loss consciousness?

Yes

No

Do you have any bone or joint problems that can be made worse by physical activity?

Yes

No

Have you been prescribed blood pressure or heart medication?

Yes

No

Do you have any skin conditions (wounds, inflammation, burns, irritations)?

Yes

No

Do you know of any other reasons of why you should avoid physical exercising? If yes, what?

Contraindications to avoid use of EMS (electro muscle stimulation) except for medical approval:

Epilepsy, pregnancy, severe disorders of blood circulation, sever neurological disorders, abdominal and inguinal hernia, tuberculosis, any state of cancer, diabetes, claustrophobia, and/or acute bacterial or viral infections.

You acknowledge that you have read and confirm that you do not have any of the conditions that are incompatible with the use of EMS (electro muscle stimulation).

Accept

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In the case of one or more of the above conditions, please upload approved clearance of use documentation from medical practitioner.