PAR-Q Form Please complete this form before participating in your first class. Your responses will remain confidential. Full Name * D.O.B * MM DD YYYY Phone Country (###) ### #### Email * Has your doctor ever said that you have a heart condition or high blood pressure, and that you should only do physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when you do physical activity? * Yes No In the past month, have you had chest pain when you were not doing physical activity? * Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? * Yes No Do you have a bone, joint or soft tissue (muscle, ligament or tendon) problem that could be made worse by engaging in physical activity? * Yes No Is your doctor currently prescribing medication for your blood pressure or heart condition? * Yes No Has your doctor ever said that you should only do medically supervised physical activity? * Yes No Do you know of any other reason why you should not do physical activity? * Yes No If you have answered "Yes" to any of the above questions please give some more details below. I, the undersigned, confirm that I have read and fully understood this Physical Activity Readiness Questionnaire (PAR-Q) to my satisfaction. I acknowledge that this clearance is valid for a maximum of 6 months from the date of completion. If I have any concerns about my health after completing this form, I understand it is my responsibility to consult a medical professional before participating in any physical activity. I also consent to Simply Pilates By Han retaining a copy of this form for record-keeping purposes. This information will be stored securely and treated as strictly confidential. * Yes Thank you for submitting the PAR-Q form. I am looking forward to seeing you at your next class.
