CORE FACTOR PILATES

Physical Activity Readiness Questionnaire

Please complete this online form to help us properly look after

you in class.

Please give full details and information relevant to your physical health and any past injuries or issues.

If you have any queries, please click here

First Name

Email Address

Surname

Mobile

Have you ever had a HEART condition or feel any CHEST PAIN when you do physical exercise? Do you lose your balance due to DIZZINESS or ever LOSE CONCIOUSNESS?

Yes

Do you have a BONE or JOINT problem that could worsen by a change in physical activity, have a MUSCULAR ISSUE restricting movement causing pain, discomfort or disturbs sleep or know a reason why you shouldn't exercise due to illness, injury, PREGNANCY? Have you given birth, had a C-section, hysterctomy or ABDOMNIAL SURGERY in last 6 months or hernias? Prescribed BP or ASTHMA medication by GP?

Yes

Please give any relevant dates of injury, illness, pregnancy or surgery. It is advisable to talk to your GP and/or Physio if you encounter any issues whilst undertaking the Pilates course programme or type NONE

Address & Postcode

Today's Date required

I confirm that I have revealed to the best of my knowledge, ANYTHING which may affect me during or as a result of exercise. If I choose NOT to consult my doctor about any condition and the suitability of undertaking this Pilates course, I do so at my own risk. I declare that the information I have provided is accurate and complete. I have read, understood and completed this questionnaire. Any questions I had prior to completion, have been answered to my full satisfaction.

THANK YOU for SUBMITTING your form! Your information is kept confidential & in accordance with the

CORE FACTOR PILATES Privacy Policy

CORE FACTOR PILATES Physical Activity Readiness Questionnaire

CORE FACTOR PILATES

Physical Activity Readiness Questionnaire