Physical Activity Readiness Questionnaire

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Name *

Date of birth *

YYYY

Occupation *

Address *

Mobile telephone number *

Email *

How did you hear about this class?

What exercises do you engage in and how many times a week?

Name things you might like to improve by practicing Pilates.

Do you suffer from fainting or dizziness? *

Yes

Do you have a heart condition? *

Yes

Do you ever feel chest pains when you do physical activity? *

Yes

Have you ever had chest pains when you were not doing physical activity? *

Yes

Do you have high/raised blood pressure? *

Yes

Do you have Diabetes? *

Yes

Do you suffer from Epilepsy? *

Yes

Do you suffer from Asthma? *

Yes

Are you pregnant? *

Yes

Have you given birth within the last 6 months or are you breast feeding? *

Yes

Do you have any joint/muscular/health conditions that could be made worse by physical exercise? *

Yes

If you have answered 'yes' to any of the above questions please give more details.

Do you know of any other reasons why you should not participate in physical exercise? *

If you have answered 'yes' to any of the above questions and/or are concerned, please speak to you GP to clarify that it is safe before starting. If you suffer with any conditions that are not listed above and you feel may be relevant to you participating in Pilates you must mention them to your instructor. *

I recognise and agree that my instructor is unable to provide me with any advice regarding my medical conditions/fitness and that the information provided is used as guidance to my ability to exercise.
I understand and agree that I am voluntarily engaging in an acceptable level of exercise, that it is important I work within my limitations and listen to my body and that participation involves risk of injury.

I have read, understood and completed this questionnaire.
I confirm that the information I have provided in this form and any other information I may later provide can be used in confidence and stored securely and will not be shared with third party without my written consent. *

YYYY

Signature *

Thank you very much for completing this form. See you soon for some Pilates to get moving and embark on a journey to become a healthier, happier version of ourselves.

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