A Questionnaire for People Aged 16 to 69

Physical activity is enjoyable and has many physical, emotional, and spiritual health benefits. Increaseing physical activity or starting physical activity is very safe for most people; however, some people should check with their doctor before they increase or start physical activity. If you are planning to engage in the mind, body, soul classes offered by In Him Christian Wellness, please answer the questions below.

If you are between the ages of 16 and 69, the Physical Activity Readiness Questionnaire (PAR-Q) will tell you if you should check with your doctor before you start. If you are over 69 years of age, check with your doctor  before attending sessions.

Please read the questions carefully and answer honestly:Check YES or NO.

If you answered YES to one or more questions:

Talk with your doctor by phone or in person BEFORE you start exercising or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and to which questions you answered YES. You may be completely fine to engage in physical activity, but these measures are for your safety.

One major key is to start slowly and build up gradually, which we will do.  You may need to restrict your activities to those that are safe for you. We have modifications for all movements in class; please mention to the instructor if you need more modifications. Talk with your doctor about the kinds of activities you wish to participate in and follow his or her advice.

If you answered NO honestly to all PAR-Q questions:

At any point, if you experience chest pain, feel light-headed, dizzy, or any other acute health, step off the the side in class immediately. Alert the instructor as to how you are feeling. And, if you need modifications to any exercises inform the instructor.

Mind, Body, and Soul:

This class addresses mind, body, and soul elements and may bring up things within each area that are of concern or you would like to discuss more. We can refer you to a counselor, if you wish to process or discuss anything that came up in mind or soul. If physical troubles arise, please discuss with Alexa Glatfelter, In Him Christian Wellness Exercise Specialist.

PLEASE NOTE:

If your health changes so that you answer YES to any of the above questions, contact your health professional and let us know.

DELAY BECOMING MUCH MORE ACTIVE.

If you are not feeling well because of a temporary illness, such as a cold or fever, wait until you feel better. If you are or may be pregnant, talk to your doctor before you become more active.

 

In consideration of me being permitted to participate in physical activity with In Him Christian Wellness, I agree to the following:

1. I acknowledge that I am voluntarily participating in a mind, body, and soul class. I have been given, read, and completed the physical activity readiness questionnaire (PAR-Q). I understand that it is my responsibility to answer these questions honestly. If I answered YES to any of the questions, it is my responsibility to seek medical attention prior to exercise. If I choose not to seek medical attention prior to starting the mind, body, and soul classes, I fully accept the risks of exercising without medical approval. I further agree and warrant that if, at any time, I believe conditions to be unsafe, I will immediately discontinue further participation in physical activity and alert my instructor if needed.

2. I fully understand that physical activity and the use of some equipment involves risks and danger of serious bodily injury, including permanent disability, paralysis, and death. I agree to release In Him Christian Wellness and its counselors, therapists, instructors, and employees from any and all liability, damages, or expense, which I have or may have against In Him Christian Wellness, arising from or relating to any accident or injury I may sustain while engaging in mind, body, soul classes.

3. If exercising indoors at In Him Christian Wellness partner locations, I take responsibility of any risks of COVID-19 or related or other illnesses. If I obtain COVID-19 or any other communicable disease, I release In Him Christian Wellness from responsibility of my health and wellness and will abstain from participating in mind, body, and soul classes until negative of this disease or illness. If I am not feeling well or have been in contact with someone testing positive for COVID-19, I will not participate in or attnd mind, body, and soul classes at In Him Christian Wellness. 

I UNDERSTAND AND ACKNOWLEDGE THAT I HAVE READ THIS ENTIRE AGREEMENT AND RELEASE OF LIABILITY AND UNDERSTAND ITS MEANING AND AGREE TO BE BOUND BY ITS TERMS.