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Core Control Pilates Health and safety questionnaire- PAR-Q
Name *
Age *
Email *
Address *
Phone number
Have you suffered from heart trouble? *
Are you presently taking any form of medication? *
Do you suffer from chest pains? *
Do you ever have spells of dizziness or feel faint? *
Have you ever had either high or low blood pressure, and/or high cholesterol levels? If YES please indicate which: *
Have you ever had asthma, chronic bronchitis or any other chest ailments? If YES please indicate which: *
Do you suffer from back pain or any orthopedic problems? If YES please indicate which:
Do you suffer from severe headaches or migraines?
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Are you recuperating from a recent illness/operation or injury? If YES please expand: *
Have you any medical conditions that I should be made aware of? *
Are you pregnant? If YES how my months? *
Is there any history of heart disease in your immediate family (under the age of 55)? *
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