*all information is confidential and follows our privacy policy

    Health Screening questionnaire (HSQ)
    SECTION 2: CURRENT AND PLANNED PHYSICAL ACTIVITY LEVEL
    SECTION 3: MEDICAL CONDITIONS (check all that apply)
    SECTION 4: Current Condition
    SECTION 5: (physical)
    Section 6: (Medications)
    Section 7: For Virtual and Fitness Support clients only
    Section 8: Informed Consent Form For Jumping JACs
    I the undersigned, give my consent to participate in the physical fitness evaluation program conducted by Jumping JACs.

    BENEFITS: Participation in a regular program of physical activity has been shown to produce positive changes in a number of organ systems. These changes include increased work capacity, improved cardiovascular efficiency, and increased muscular strength, flexibility, power and endurance.

    RISKS: I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and the cardio-respiratory system (dizziness, discomfort in breathing, heart attack).

    Declaration: I hereby certify that I know of no medical problem (except those noted above) that would increase my risk of illness and injury as a result of participation in a regular exercise program.

    Testing and Evaluation Results: I understand that I may undergo initial testing to determine my current physical fitness status. The testing may consist of completing this health inventory, taking a step test or bicycle ergometer test for cardiovascular fitness, and being tested for muscular fitness and body composition. I further understand that such screening is intended to provide Jumping JACs with essential information used in the development of individual fitness programs. I understand that my individual results will be made available only to me. I also understand that the testing is not intended to replace any other medical test or the services of my physician. I will be provided a copy of all test results. I may share the results with whomever I please, including my personal physician. By signing this consent form I understand that I am personally responsible for my actions during my tenure at/with Jumping JACs, and that I waive the responsibility of Jumping JACs if I should incur any injury as a result of my negligence.