Physical Activity Readiness Questionnaire
Please answer the questions below. If you are between the ages of 15 and 69 the questionnaire will tell you if you should check with your doctor before you start to exercise. If you are over 69 years of age, please check with your doctor before becoming more physically active.
1. Has your doctor 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 ever feel pain in your chest when you do physical activity? YES/NO
3. Have you ever had chest pain when you are not doing physical activity? YES/NO
4. Do you ever feel faint or have spells of dizziness? YES/NO
5. Do you have a joint problem that could be made worse by exercise? YES/NO
6. Have you ever been told that you have high blood pressure? YES/NO
7. Are you currently taking any medication of which the instructor should be made aware of? YES/NO
8. Have you had a baby within the last 6 months? (You will need a one-to-one session before attending a class if you are new to Pilates and are pregnant). YES/NO
9. Is there any other reason why you should not participate in physical activity? YES/NO
If YES, please give details(PTO IF NECESSARY):
_____________________________________________________
10.What are your motives for exercising?
If you have answered yes to one or more questions, talk to your doctor by phone or in person before you start to become more physically active. Tell your doctor about the questionnaire and which question you answered yes to. You may need to restrict your activities to those that are safe for you or to build up activity slowly and gradually. If your health changes so that subsequently you would answer yes to any of the above questions, inform your instructor immediately.
Nnname: _________________________________________________________
Adaddress: _______________________________________________________
Tetelephone number: ___________________________________
e- e-mail ____________________________________________
EeEmergency Contact Name and Tel:
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I HAVE READ, UNDERSTOOD AND COMPLETED THE QUESTIONNAIRE.
Signature _________________________________________
I, ___________________________________________ (print name) 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 penalize, prosecute or claim compensation from Patricia Susan Robertson for any injury, loss or damage. Signature ______________________________ Date__________________
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