PAR-Q Form for Sam Gurner Pilates

Client information & PAR-Q
Client Information
Full name*

First NameLast Name
Date Of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
Emergency contact*

First NameLast Name
Phone number*

Area CodePhone Number
Health questionnaire (Par-Q)
Please read the following 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 have they cleared you for physical exercise?
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 worsened by a change in your physical activity?
Are you taking any regular prescription medications? (Please specify and for what condition in the comments box below)
Do you have any other medical conditions which could affect your ability to exercise?
Are you injured?
If you answered yes to the previous question have you been cleared to exercise by your GP?
Could you be pregnant or have you been in the last six months?
Do you currently exercise on a weekly basis?
Do you know of any other reason why you should not do physical activity?

Client information & PAR-Q