Here Pilates
PAR Q
PAR Q
Physical Activity Readiness Questionnaire
PAR-Q
First Name
Last Name
Email
Contact number
Date of birth
Address Line 1
Address Line 2
City
Post Code
Has your doctor ever said that you have high blood pressure?
Yes
No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No
Have you ever been diagnosed with any other medical condition other than heart disease or high blood pressure?
Yes
No
Please list conditions below.
Are you currently taking prescribed medications for a chronic medical condition?
Yes
No
Please list medications below.
Have you lost consciousness in the last 12 months?
Yes
No
Do you ever lose balance because of dizziness?
Yes
No
Do you currently have or have you had in the last 12 months a bone, joint or soft tissue problem that could be made worse by becoming physically active?
Yes
No
Has your doctor ever told you that you should only do medically supervised physical activity?
Yes
No
I consent to have this website (Here Pilates) store my submitted information for their records and may be used in assessing suitability for exercise. By submitting this form I confirm that I have read and completed this form to the best of my knowledge and ability.
By ticking this box, I acknowledge that I am participating in this exercise program voluntarily and at my own risk.
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