Health Questionnaire (PAR-Q)

All Information given will be treated confidentially. Please complete all sections and sign prior to your first session with us.

First Name *

Last Name *

Phone *

Email *

Address

Street Address *

Town/City

County

Postcode

Date of birth *

Occupation *

Emergency contact number *

Emergency Contact Name *

Do you have any Allergies or Intolerances? *

If you are planning to take part in a class with us and you are new to this form of exercise, start by answering the questions below. If you are over 69 years of age, and you are not used to being very active, please check with your doctor before attending your first session.

Have you done any Pilates before? *

Never

I have attended classes in the last month

I have attended just a couple of classes before but longer than 6 months ago

I used to attend regularly, but not in the last 6 months

I have not attended in the last 12 months

Other

If you selected other in the previous question please explain (if not type NA) *

Do you do any other forms of exercise or sports regularly? If so what? *

Does your job involve any of the following (please select all that apply) *

Any other repetitive action, please specify (please put NA if not) *

Do you ever have spells of dizziness or feel faint? *

Yes

Has your Doctor ever said that you have any sort of heart trouble or defect? *

Yes

If yes, please give details. (please put NA if not) *

Have you ever had Asthma, Chronic Bronchitis or any other chest ailments? *

Asthma

Chronic Bronchitis

None

Other

If you selected other please specify. (Type NA if not) *

Have you ever been told that you have arthritic joints, osteoporosis, osteopenia or any bone or joint problem that may affect your ability to exercise? *

Yes

If yes, please give details (Type NA if not) *

Do you suffer from severe headaches or migraines? *

Yes

If you answered Yes to the above question please give details (type NA if not) *

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

Yes

If yes, please give details (type NA if not) *

Have you had minor surgery in the last 2 years? *

Yes

If yes, please give details (type NA if not) *

Have you ever had either high or low blood pressure, and/or high cholesterol level? Please tick all that apply *

High Blood Pressure

Low Blood Pressure

High Cholesterol

None of the above

Do you have any pain or restricted movement in any other joints? (e.g hip, knee, ankle, shoulder) *

Yes

If yes, please give details (type NA if not) *

Are there any movements or positions which cause you pain? *

Yes

If yes, please give details (type NA if not) *

Do you have neck or back pain? *

Yes

If yes, please give details. (type NA if not) *

Is there anything else in your medical history that you feel could affect your ability to exercise? *

Yes

If yes, please give details (type NA if not) *

Are you taking any medications that may affect your ability to exercise? *

Yes

If yes, please give details (type NA if not) *

Are you currently seeing a Physio/Osteo/Chiropractor or similar therapist? *

Yes

Physio/Osteo/Chiro Name (Type NA if not relevant) *

(Women only) Are you pregnant or have you had a baby in the last 12 months?

Not pregnant

Pregnant

Had a baby in the last 12 months

PLEASE NOTE - If you have answered pregnant or had a baby in the last 12 months, you will be sent a second form to complete - please check your emails after submitting this form

Name of friend that told you about us so we can thank them?

If you saw a poster, please let us know where you saw it displayed.

Disclaimer

I understand that The Pilates Corner instructors use hands-on correction and I hereby consent for my instructor to work in this way.

I understand that I will be charged for my class if I do not give 12 hours' notice of cancellation (24 hours for private sessions).

Exercise should be performed at a pace which feels comfortable for you. PAIN is the body's warning system and should NOT BE IGNORED. You must take responsibility for your own body during each Chair/Mat Pilates session and must inform the instructor if you feel any discomfort. Please also inform the instructor if you felt any discomfort after a previous session. The instructor can accept no liability related to the participation of the class if: 1) The doctor has advised you against such exercise. 2) You do not act responsibly with your body or fail to observe instruction on safety or technique. 3) Such injury is caused by the negligence of another participant in the session/studio.

It is important that you advise us before commencing any session if, for any reason, your health or ability to exercise changes.

Chair/Mat Pilates is a very safe form of exercise, however as with all forms of exercise it is prudent to consult your doctor if you suffer from any health problems or special conditions, or if you are in any doubt as to its suitability. If you are undergoing any medical treatment or are taking medication, you will need to consult your medical practitioner first. Pilates should not be considered a replacement for professional medical counselling or treatment.

I confirm that I have read and understood the above advice and that the information I have given here is correct.

Signature *

Clear

Date of Signature *

If the button doesn't seem to be clickable, it means you have missed an answer that is required on the form.