PAR-Q Form

First Name *

Last Name *

Email *

Phone *

Year You Were Born

Who Should We Contact In Case of Emergency?

Contact's Name

Contact's Phone Number

Medical History

provide surgery Last

Have you had surgery in the last 10 years? *YesNo

Surgery History

If you answered YES, please give brief details

Have you suffered, or do you suffer, from any of the following?

• Asthma
• Diabetes (Type 1)
• Diabetes (Type 2)
• Epilepsy
• High/Low Blood Pressure
• Fainting/Dizziness/Headaches
• Hearing Loss
• Joint Problems
• Back Problems
• Arthritis
• Heart Condition

If you have ticked any of the above, please provide details

Are you pregnant? *NoYes

If YES, when is your baby expected?

Please outline any other conditions which may affect your ability to exercise

Daily Activities

Your Occupation

How frequently do you exercise?

What type of exercise?

Confirmation

Declaration *

• I acknowledge that I am fully responsible for monitoring my capability to participate in any exercise session, that I will advise Pilates4Living of any health or medical conditions that may affect my participation. I also acknowledge that I have answered the questions accurately and to the best of my ability and that I understand the contents of this questionnaire.

Date *

Submit

Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the 7 questions.