Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile telephone number *

Country

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1. Has your health professional ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

2. Do you feel pain in your chest when you do physical activity? *

Yes

No

3. In the past month, have you had chest pain when not doing physical activity? *

Yes

No

4. Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? *

Yes

No

6. Are you taking any medications, which may affect your ability to exercise? *

Yes

No

7. Do you know of any other reason why you should not do physical activity? For example, could you be pregnant? *

Yes

No

If you answered YES to one or more of the questions above you hereby confirm you have spoken with your doctor by phone or in person BEFORE starting more physically activity, and/or BEFORE you have a one on one Pilates appraisal, with SW19 Pilates. *

Yes

No

Not applicable (did NOT answer 'Yes' to any of the above questions)

If you answered NO to all questions above please confirm you are reasonably sure that you can start becoming more physically active.

Yes

Not applicable (as I answered 'YES' to one or more of the questions above)

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 agree that you will inform me immediately if you feel any discomfort during (or after) a session. *

Yes

You agree that the teacher can accept NO liability for personal injury related to participation in a session if: *

– Your doctor has, on health grounds, advised you against such exercise. – You fail to observe instructions on safety or technique.

Yes, I agree

I hereby confirm that I have read, understood and completed this PAR-Q. Any questions I had were answered to my full satisfaction and I acknowledge that any advice received from SW19 Pilates is not a substitute for my doctor’s advice. *

Yes, I hereby give my full consent that I have read, understood and completed all of the above including seeking medical advice.