PILATES PAR-Q / SCREENING FORM / PRE-EXERCISE HEALTH QUESTIONNAIRE
NAME:
DATE OF BIRTH:
ADDRESS:
HOME TEL:
MOBILE:
EMAIL:
EMERGENCY CONTACT NAME:
EMERGENCY CONTACT NO:
Please CIRCLE the appropriate answer accurately to help me provide you with the highest level of service.
Has your Doctor ever indicated that you have heart condition? Y / N
Has your Doctor ever said that you suffer from high blood pressure? Y / N
Have you ever been made aware that your cholesterol was high? Y / N
Do you have severe chest pains during physical exertion? Y / N
Do you experience any dizziness or fainting? Y / N
Do you have any bone, joint or muscular problems? Y / N
Are you Pregnant or have you been pregnant within the last 6 months? Y / N
Are you diabetic? Y / N
Please indicate which type Type I / Type II
Do you suffer from arthritis? Y / N
Are you taking any medication or prescribed drugs? Y / N
Do you suffer from Epilepsy? Y / N
Do you suffer from Asthma? Y / N
Please provide any other details you would find relevant prior to undergoing physical exercise on the back of this form.
If you have answered YES to any of the above, you may be required to contact your GP to obtain clearance prior to undergoing any Pilates classes with Pilates N12.
Terms and Conditions
I have read and completed this form in its entirety and answered all questions accurately. I understand that I am responsible for monitoring myself throughout exercising with Pilates N12 and Group exercise classes and take full responsibility for my own actions. I will inform my instructor if any symptoms or changes occur.
Client Signature ……………………………………………….. Date
Instructor Signature …………………………………………… Date
Information supplied will be treated confidentially