Hi and welcome to WELL Inc’s Personal WELLnalysis Self-Evaluation Process!

  • The Health and Injury Physical Activity Readiness Form below is a necessary part of this process, because it helps to identify any pre-existing health conditions¬†or injuries that could be affected by exercise.
  • If you answer yes to 2 or more of these questions, it is recommended that you consult with your physician prior to participating in the WELLnalysis Workout or any of the fitness programming offered through WELL Inc.
  • It is important to be as thorough as possible, so that we can provide the right solution based on your individual needs.

 

Your WELL Specialist's Name (If applicable)

Your Name (required)

Your Email (required)

Your Phone Number

Your Date Of Birth (required for age verification)

Emergency Contact Name and Relationship (required)

Emergency Contact Phone and/or email (required)

Your Occupation

Part 1 - Health and Injury PAR-Q. Please be as detailed as possible when completing this section, as it will help identify your potential restrictions prior to exercise.

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?

Do you frequently have pains in your chest when performing physical activity?

Have you had chest pain when you were not doing physical activity?

Do you lose your balance due to dizziness or do you ever lose consciousness?

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?

Are you pregnant now or have you given birth within the last 6 months?

Have you had a recent surgery?

If you have marked YES to any of the above, please elaborate below:

Do you take any medications, either prescription or nonprescription, on a regular basis?

What is the medication for?

How does this medication affect your ability to exercise or achieve your fitness goals?

If you answered YES to more than two of the questions above, it is highly recommended that you speak with your doctor prior to engaging in physical activity of any kind. If this is the case, please do not move forward until your doctor has approved you to do so. Thank you!