Health PAR-Q for Pilates in Cumbria
Please provide your health information to ensure a safe Pilates experience.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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 feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
*
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 that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
*
Yes
No
Are you currently pregnant?
*
Yes
No
Not applicable
Do you know of any other reason why you should not do physical activity?
*
Yes
No
If you answered YES to any of the above questions, please provide more details
Please list any recent surgeries, illnesses, or injuries
Please list any medications you are currently taking
Please provide any other relevant health information or concerns
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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