Pilates with Fi — PAR-Q New Client Health Screening
Before we begin working together, I need to gather some information to ensure all sessions are safe and effective for you personally. Please answer each question honestly. This form is completely confidential. If you are between 18–69 years of age, this PAR-Q checklist will help you assess your readiness for physical activity. If you are over 69 years of age and not already exercising regularly, please check with your doctor before we begin.
Your Details
Full Name
*
First Name
Last Name
Date
*
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Day
-
Month
Year
Date
Address
*
Postcode
*
Date of Birth
*
-
Day
-
Month
Year
Date
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: +44 0000 000 000.
Next of Kin
*
Emergency Contact Number
*
Please enter a valid phone number.
Format: +44 0000 000 000.
Health Screening Questions
Please answer each question honestly with YES or NO.
Heart condition / doctor-only physical activity
*
Yes
No
Chest pain during physical activity
*
Yes
No
Chest pain in the past month when not doing physical activity
*
Yes
No
Dizziness, loss of balance, or consciousness
*
Yes
No
Bone or joint problem (e.g. back, knee, or hip) worsened by change in physical activity
*
Yes
No
Doctor currently prescribing medication for blood pressure or heart condition
*
Yes
No
Currently pregnant or gave birth in the last 12 weeks
*
Yes
No
Any other reason not to participate in physical activity
*
Yes
No
If you answered YES to any question above, please provide details below.
Declaration and Signatures
Declaration confirming completion and acceptance
Client Signature
*
Signature Date
*
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Day
-
Month
Year
Date
Submit
Submit
Should be Empty: