Pilates Guy - Health & Safety Questionnaire (PAR-Q)

Pilates Guy - Health & Safety Questionnaire (PAR-Q)

Please complete the following form, read and understand the Informed Consent Declaration and sign. All personal and sensitive data will be stored in compliance with GDPR
Name*

First NameLast Name
Email*
example@example.com
Phone number
Date of birth*

DayMonthYear
Date
Emergency contact name*

First NameLast Name
Emergency contact phone number*
Emergency contact relationship
Your occupation
Have you done any form of Pilates before?*

NeverOnce or twice so consider me a beginnerQuite a bit, I know the basicsExperienced

Is there anything in particular you would like to gain from Pilates? Select all that apply

Improved sports performanceLessen occurrence of injuryRecover from injuryImprove postureImprove core strengthAid existing back painGeneral self care - avoiding potential problemsImproved mobilityImproved flexibilityGeneral strengthBalanceLose weightImprove current level of fitnessOther
I would like to subscribe to the weekly Pilates Guy e-mail which includes useful content, videos, session updates and booking details*

YesNo
Health Questionnaire

Do you suffer from any of the following?*

	Yes	No	N/A
Have you ever suffered from any heart condition?
Are you presently taking any form of medication?
Do you suffer from chest pains?
Do you ever have spells of dizziness or feel faint?
Have you ever had either high or low blood pressure
Have you ever had a high cholesterol level?
Have you ever had asthma, chronic bronchitis or any other chest ailments?
Do you suffer from back or neck pain or any orthopaedic problem?
Do you suffer from severe headaches or migraines?
Are you recuperating from a recent illness/operation or injury?
Have you any medical condition that we should be aware of?
Are you pregnant? Please indicate how many weeks in additional info section
Is there any history of heart disease in your immediate family (under the age of 55)

Additional Information
If you have answered "yes" to any question on the health questionnaire, please provide details here along with any other additional information
Full details where any question has been answered yes above
Importantly, should you have answered YES to any question on the health questionnaire, you are also advised to seek medical advice/approval before commencing an exercise induction or exercise programme or consult further with your instructor.

Declaration

I have been informed both verbally and in writing that if I answer YES to any of the questions on the health questionnaire, I should seek medical advice/approval before commencing an exercise programme and/or induction.

If I wish to continue without such advice I do so entirely at my own risk. I confirm that I have read, fully understood and answered the above questions honestly.

I understand that the instructor cannot be held responsible for any injuries or ill health arising from my participation in the exercise programme.
Name*

First NameLast Name
Client Signature*

Clear
Date*

DayMonthYear
Date
Pilates Informed Consent Declaration
I hereby state that I have read, understood and answered honestly the questions on the PAR-Q. I wish to participate in physical activities that will include a Pilates warm-up preparation phase involving standing and lying exercises and a main mat-based Pilates session with floor-based exercises. These could involve use of small equipment such as a resistance band, blocks, foam rollers or Pilates rings. The session will also include flexibility exercises.

I realise that in participating in these activities I may be at risk of injury and even the possibilty of death. I hereby confirm that I am participating voluntarily.
Name*

First NameLast Name
Client Signature*

Clear
Date*

DayMonthYear
Date
Additional note: I confirm that, if necessary, I have taken medical advice and my doctor has agreed that I should exercise
Name

First NameLast Name
Client Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

Pilates Guy - Health & Safety Questionnaire (PAR-Q)

Health Questionnaire

Additional Information

Pilates Informed Consent Declaration