Health Questionnaire
Charlotte Ward Yoga and Pilates
Please complete and submit this physical activity readiness questionnaire (PARQ) before taking part in any activities.
Full Name
First Name
Last Name
Date of birth
Contact Number
-
Area Code
Phone Number
Email Address
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
-
Area Code
Phone Number
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No
Do you ever feel pain in your chest when you do physical activity?
Yes
No
Do you suffer from epilepsy?
Yes
No
Would your doctor currently say you have high or low blood pressure?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem, for example, back, knee or hip? If you answer yes you are advised to seek advice from a health care professional first. See declaration below
Yes
No
Is your doctor currently prescribing drugs for blood pressure or a heart condition? If you answer yes you are advised to seek advice from a health care professional first. See declaration below
Yes
No
Are you pregnant or have you had a baby in the last 6 months? If you are pregnant, how many weeks will you be for your 1st class
Yes
No
Weeks pregnant
Is there any other reason why you should not participate in physical activity?
Yes
No
If yes please state why below
IF YOU HAVE ANSWERED YES TO ONE OR MORE QUESTIONS
You should talk to your doctor by phone or in person before you start becoming more physically active. Tell your doctor about the questionnaire and which questions you answered YES to. Please also tell your instructor. If you have already got medical clearance for Yoga/Pilates or moderate exercise in general, please fill in the declaration below.You may be able to do any activity you want – as long as you build up slowly and gradually. Or you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activity you wish to participate in and follow his/her advice. Yoga/Pilates exercises are generally safe for most people, it improves flexibility and strengthens your deep postural muscles – particularly your deep abdominals and back muscles – as well as improving your overall posture and body awareness, thus minimising the chance of future injuries. If your health changes subsequently so that you answer YES to any of the above questions and you have started a class with us, please inform your teacher. If you are temporarily unwell (e.g. cold or flu), delay becoming more active until you are better.If your doctor has recommended that you avoid any movements, make sure that you let your teacher know.
IF THE ANSWER IS NO TO ALL QUESTIONS
You can reasonably be sure that you can start to become more physically active and take part in a suitable exercise programme. Begin slowly and build up gradually.
Confirmation
By submitting this booking form you confirm you have read and understand this questionnaire. If you have any concerns, contact us by email and ensure you speak with your instructor at the start of your class.
Consent Form
I understand that taking part in yoga or Pilates classes or 121s will involve participation in exercise & physical activity. I understand the short-term effects of exercise that include: increase in Blood pressure, increase in Heart Rate, Increase in body temperature, increase in respiratory rate increase, shortness of breath, sweating & fatigue. I understand that if I am pregnant or have recently had a baby, I have been advised of certain risks which may occur during exercise and I have had clearance by my GP or midwife to participate in exercise classes. I do however take full responsibility of myself during any sessions/classes with my teacher. Lotty.fit has a duty of care to ensure the risks associated with exercise are minimal, but I take full responsibility of myself whilst participating in exercises classes.
Declaration
DECLARATION This applies if you have answered yes to any of the above questions. I declare I have been cleared by my doctor (GP, specialist or other qualified health professional) to take part in moderate exercise. By submitting this document this indicate your informed consent.
Submit
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