EveryBod Pilates Physical Health Questionnaire

Full name*

First NameLast Name

Birth Date*

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

E-mail*

Emergency contact*

First NameLast Name

Phone number*

Area CodePhone Number

Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q*

	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?
Has any of your immediate family developed heart disease before the age of 60?
Do you feel fain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you suffer with lower back pain?
Do you have asthma?
Do you have epilepsy?
Are you pregnant or given birth/miscarried in the last 6 weeks?
Do you know of any other reason why you should not do physical activity?

If you're on any medications, please list them and state what they're for

If you have any current or previous injuries, please list them

Have you seen any Specialists seen in past 12 months (Physiotherapist / Chiropractor etc)?

What is your fitness level?

Signature of Parent/Guardian if under 18*

1. That I am participating in the Health & Fitness Classes, Programs or Workshops offered by Boost Camp and EveryBod Fitness during which I will receive information and instruction about health and fitness. I recognise that fitness programs require physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Health & Fitness Classes, Programs or Workshops. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in the Exercise Classes, Health Programs or Workshops.

3. In consideration of being permitted to participate in Health & Fitness Classes, Programs or Workshops, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program.

4. In consideration of being permitted to participate in Health & Fitness Classes, Programs or Workshops, I knowingly, voluntarily and expressly waive any claim I may have against Boost Camp and EveryBod Fitness for injury or damages that I may sustain as a result of participating in the program.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

Signature*

Date*

DayMonthYear

Name

First NameLast Name

Relationship to client

Enter the message as it's shown*

Physical Health Questionnaire

Health questionnaire (Par-Q)

Client information - Signature