PAR-Q: Mindful Pilates

Client Information

If you are planning to take part in physical activity or an exercise class and you are new to the exercise, start by answering the questions below and make sure you include your name and contact details. By completing the questionnaire you will be providing information to your instructor that may affect the exercises in the class. Any potential issues that are flagged within you will be advised that you check with your GP prior to committing to a class and I will seek a Specialist signature if necessary. All information provided will be treated in the strictest confidence under the Data Protection act..
Full name *

First Name Last Name
Birth Date

Day Month Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Phone Number *

Area Code Phone Number
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone number *

Area Code Phone Number
Health questionnaire (Par-Q)

Physical Activity Readiness Questionnaire.
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 suffer with any joint issue. Eg. Carpal Tunnel Syndrome (Wrist, finger, hand, forearm pain / numbness or tingling). Any knee pain, or sacrum or sacroiliac joint pain. Back pain? If so, please describe below.
Is your doctor currently prescribing drugs (for example water pills) for blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Are you pregnant or have given birth in the past 6 months?
Do you have any injuries?
Do you take any medication?
Do you suffer from back pain?

If you answered Yes to any of the above questions. Please provide any further details here:
Initials *

Clear
By signing yes, you agree that you fully understood the questions, you have answered honestly, that you have written permission if required. You understand that you are participating voluntarily and have no known reason why you would be unable to voluntarily participate in any physical exercise. * *
Initials *

Clear
12hr Cancellation Policy
Late Cancellations and No Shows will be charged for.

Drop in. If you are unable to attend you can reschedule 12hrs before class to avoid losing your credit.

Cancel a drop in class and you will lose your credit.

Class Pass. With a Class Pass credit will be issued back to the client's account if cancelled before the 12hrs, full class fees will apply outside of this time frame.

All payments are non-refundable or transferable.
Initials *

Clear
Date

Jour Mois Année
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