83 Pilates PAR-Q

This form is a tool to determine whether you need to check with a doctor before starting a new form of exercise. If you are under 16, please let your instructor know so we can discuss whether this class is suitable or to discuss alternative classes. If you are over 69 years of age and not used to being active, please make sure you check suitability with your GP. Please read each question carefully and answer completely and honestly.

YES/ NO*

Rows	Yes	No
Has your doctor ever said that you have a heart condition and/ or that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
Do you ever feel chest pain during daily living activities?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Is there any history of coronary heart disease in your immediate family?
Do you have a diagnosed illness that could be made worse by physical activity?
Are you prescribed medication for your blood pressure, diabetes or heart condition?
Are you pregnant now or have given birth within the last 6 months?
Have you had a recent surgery?
Have you ever suffered from unusual shortness of breath at rest or with mild exertion?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Do you have arthritis, osteoporosis, osteopenia or disc problems?
Do you have cancer or are currently receiving cancer therapy?
Have you had surgery in the past 12 weeks?
Do you know of any other reason why you should not do physical activity?

If you answered YES to any of the above, you should ensure your GP has confirmed that it is safe for you to become physically active at this current time and in your current state of health. By signing this form you confirm that your doctor has given specific clearance to undertake this class.

If the answer to all questions is ‘NO’ we can assume it is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. However, if you have any concerns please inform your instructor below;

If your health changes at any time you MUST inform you instructor before your next class.

Informed consent

Pilates can have great health benefits and improve cardiovascular fitness, muscle strength, endurance and flexibility. However exercise can contain risks such as muscle strains, joint sprains, aches, pains, injury or even death. Your instructor will provide different levels for the exercises to minimise these risks, however, if at any time during the exercise programme you feel pain, discomfort or you feel unwell you must stop immediately.

Please confirm..*

Rows	Yes	No
I confirm that I am voluntarily engaging in exercise knowing that my participation involves risk.
I understand that it is my responsibility to choose the appropriate level of exercise for my ability.
I participate at my own risk and accept full responsibility for the risk of any injuries or damages that may occur during or following my lesson.
I am happy for images taken in class to be used as promotional material (and) on social media.

Your information*

Full namePhone number

Email

example@example.com

Date of birth

Date

Emergency contact *

NamePhone number

Please confirm..*

Rows	Yes
I have read, understood and honestly completed the questionnaire.
I understand that I must notify you immediately of any changes in my health.
I have had the opportunity to ask any questions or express any concerns.
I will act with all due care to safeguard my own safety and that of fellow students.

Signature*

Data Protection information

Your personal information is requested to allow us to ensure safe practice. The information you provide will be kept securely and is not shared with any third parties. Although regular updates will be requested, unless otherwise instructed by you, this form will be kept for 6 years.

Equality and inclusion

Please let me know if you have any learning difficulties or impairment that might require some additional support, either during the lessons or in future communications (including visual or hearing impairment).