PAR-Q for Pilates Clients
Physical Activity Readiness Questionnaire for Pilates by Beth. Please answer all questions honestly to help us ensure your safety.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have a heart condition or have you ever been told by a doctor 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 any joint or bone problems that could be made worse by a change in your physical activity?
*
Yes
No
Are you currently taking any prescribed medications for a chronic condition?
*
Yes
No
Have you had any recent surgery or medical procedures?
*
Yes
No
Are you currently pregnant or have you given birth in the last 6 months?
*
Yes
No
Not applicable
Do you have any other health issues or conditions not listed above that may affect your ability to participate in Pilates?
*
Yes
No
If you answered 'Yes' to any of the above, please provide details.
Emergency Contact Name
*
First Name
Last Name
Relationship to Emergency Contact
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature (Type your full name as consent)
*
Submit
Submit
Should be Empty: