Physical Activity Readiness Questionnaire (PAR-Q)

Name *

First

Last

Email *

Contact Telephone Number *

Date of birth *

Emergency Contact Name *

First

Last

Emergency Contact Telephone Number *

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

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

3. Have you ever had chest pain when you were not doing physical activity?* *

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

5. Do you have a joint problem that could be made worse by exercise?* *

6. Have you ever been told that you have high blood pressure?* *

7. Are you currently taking any medication of which the instructor should be made aware?* *

If you answered Yes to Question 7 please list medication details below:

8. Are you pregnant or have you had a baby in the last 6 months?* *

9. Is there any reason why you should not participate in physical activity? If so please give details below: *

10. What level of physical activity do you currently undertake? (detail any fitness programme or activity within your employment): *

11. What is your primary motive for exercising? *

12. If you answered Other for question 11 please state your reasons here:

13. What level of physical activity do you currently undertake? (detail any fitness programme, hobby, routine activity or work related):

14. Please provide any additional information here that you feel Helen should know:

15. Please select your motivations for doing Pilates: *

16. How did you find out about Studio 6?

I HAVE UNDERSTOOD AND COMPLETED THIS QUESTIONNAIRE. ALL QUESTIONS WERE ANSWERED TO MY FULL SATISFACTION.* *

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