PAR MED X

PAR-Q Plus (Medical PAR-Q)

House of GlamRock – Extended Medical PAR-Q+

Complete this only if you answered YES to any of the above questions, or are over the age of 69 and not used to vigorous activity.

Please consult with your physician and have them complete the section below if clearance is recommended:

Physician Name: ___________________________ Phone: __________________ Signature: ___________________________ Date: __________

Client Acknowledgment: ☐ I have received physician clearance. ☐ I am waiting for physician clearance. ☐ I have been advised against participating at this time.