Nina Scott Pilates - Par-Q Form

Full name*

First NameLast Name

E-mail*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date*

MonthDayYear

Gender

Occupation

Number of children

Emergency contact*

First NameLast Name

Emergency contact phone number*

Area CodePhone Number

Doctor's name*

Doctor's phone number*

Area CodePhone Number

Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, neck, knee, or hip) that could be worsened by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?

Have you ever been treated or diagnosed for any of the following?*

	Yes	No
Anemia
Diabetes
Epilepsy
High blood pressure
Arthritis
Stroke
Osteoporosis
Obesity
Depression

If you answered yes to any of the questions above, please submit a Doctor's certificate before participating in Pilates classes.

Please stipulate any surgical operations you have had:

Please indicate your reason for participating in Pilates:

	Yes	No
Flexibility
Core strength
Body shape
Toning
Weight loss
Injury recovery
Improved posture

If you have other reasons, please list below:

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction

Initials

Please note:

As with any exercise program, you must follow the instruction given. Failure to do so may result in an injury, in respect of which the course organiser will have no responsibility.

The instructor has relied on the information supplied by you on this form. However, I do not profess to give medical advice and if you received advice not to exercise you must adhere to same. Under no circumstances must you continue with exercise that causes you pain or discomfort, as the organiser will have no responsibility for the injury arising from same.

Please acknowledge with your initials below -

Initials

Data protection:

Your contact information will be used for communication purposes and will never be shared with any third party. In order to adhere to GDPR requirements, please consent to being contacted for each of the following options by ticking each box below as required:

I am happy to be contacted about:

Updates for classes which you are currently taking part inNew classes and workshops from Nina Scott PilatesGeneral information about Pilates, general fitness and well-being from Nina Scott Pilates

Par-Q Form

Clients information - Health questionnaire (Par-Q)