Gym health questionnaire Form

EMBRACING PILATES

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE. (Par-Q)
Full name*

First NameLast Name
Address*

Street Address

Street Address Line 2

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E-mail*
Phone Number*

Area CodePhone Number
Emergency contact*

First NameLast Name
Phone number*

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Clients informations - Health questionnaire (Par-Q)
Common sense is your best guide when you answer this questionnaire. 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?
Do you feel pain 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?
Have you ever had either high or low blood pressure
Do you know of any other reason why you should not do physical activity?
Are you pregnant

I have read, understood and completed this questionnaire.
Initials*

Clear
Client informations - Liability waiver
I have been informed both verbally and in writing that if I answer `YES` To any of the questions 1-8 of the 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 honestly, and I understand that Denise Dobbins or Embracing Pilates cannot be held responsible for any injuries or ill health arising from my participation in the classes.
Initials*

Clear
Client informations - 24h cancellation policy
All cancellations must be received at least 24h before your training session in order to avoid being charged.

Embracing Pilates understands that emergencies happen. We provide every client with one free short-notice cancellation. You will not be charged for your first cancellation with less than 24h notice. Subsequent short notice cancellations will be charged for the session. The free short-notice cancellation only applies if Embracing Pilates is notified prior to the session start time. No show are not eligible for the free cancellation.
Client informations - Signature
Signature*

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Date

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