TNXL Fitness Assessment

Player Name*

First Last

Player DOB*

Player Phone*

Player Email*

Height*

Weight*

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Physician's Name

Physician Phone

Physical Activity Readiness Questionnaire (PAR-Q)

If you have answered “yes” to one or more of the below questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*

Yes
No

Do you feel pain in your chest when you perform physical activity?*

Yes
No

In the past month, have you ha chest pain when you were not performing any physical activity?*

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness?*

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness?*

Yes
No

Do you have bone or joint problems that could be made worse by a change in your physical activity?*

Yes
No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?*

Yes
No

Do you know of any other reason why you should not engage in physical activity?*

Yes
No

Have you ever had any pain or injuries? (ankle, knee, hip, back, shoulder etc.)*

Yes
No

If yes please explain

Have you ever had any surgeries?*

Yes
No

If yes please explain

Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease hypertension (High Blood Pressure), high cholesterol or diabetes?*

Yes
No

If yes please explain

Are you currently taking any medications?*

Yes
No

If yes please explain

I have read and completed this assessment form.

Athlete Signature*

Name*

First Last

Date*

Parent/Guardian Signature*

Name*

First Last

Date*

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