Ultimate Pilates - Complete my Pysical Activity Readiness Questionnaire

Physical Activity Readiness Questionnaire (PARQ)

Your details
First name:
Surname:
Address:
Postcode:
Tel:
email:
D.O.B. (dd/dd/yyyy):
Medical History
Yes
No
Do you suffer Back / Shoulder / Hip / Knee Pain?
Details:
Do you suffer any joint conditions ie Arthritis?
Details:
Do you suffer High or Low Blood Pressure?
Details:
Have you ever had a Bone Density Count?
Details:
Have you recently given birth?
Details:
Have you recently had any injuries or operations?
Details:
Are you currently taking any medication?
Details:
Any other information you may think is relevent
Client Release Statement
I willingly participate in the practical exercises at my own risk. I have no physical restrictions, disabilities or any predisposition to sickness or injury that may be aggravated or adversely affected as a result of my participation. I take full responsibility for any injury, loss or damage to my person or property that may arise directly or indirectly from my participation in the exercises. I will not seek to penalise, prosecute or claim compensation from the company for any injury, loss or damage.
By checking this box and typing my name I agree to the above statement, and certify that the information I have provided in this form is acurate and applicable to me.
Name:
Date: