Waiver Form – theoriginpilates.com

Name

Date

Phone

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

Yes No

2. Do you feel pain in your chest when performing physical activity?

Yes No

3. Have you experienced chest pain when NOT performing physical activity in the last month?

Yes No

4. Do you lose your balance because of dizziness or have you lost consciousness recently?

Yes No

5. Do you have any bone or joint problems (e.g Back, Knee, Hip) which could be aggravated by physical activity?

Yes No

6. Are you diabetic?

Yes No

7. Do you have epilepsy or suffer from seizures?

Yes No

8. Is your doctor currently prescribing you any medications for high blood pressure or a heart condition?

Yes No

9. Are you pregnant or have you been pregnant in the last 6 months?

Yes No

10. Are you currently taking any medication? If yes, what and for what reason?

Yes No

11. Do you have COPD or pre-existing lung/respiratory conditions?

Yes No

12. Do you have schizophrenia, unmedicated bipolar disorder or psychosis or unmanaged PTSD?

Yes No

13. Have you had recent major surgery, especially abdominal?

Yes No

14. Do you have glaucoma and/or detached retina?

Yes No

15. Is there any reason why you should not participate in physical activity?

Yes No

If yes, please state your reason….

Note: If you answered YES to one or more questions, it is advisable to talk with your doctor before you start becoming much more physically active or before you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want – as long as you start slowly and build up gradually. Or you may need to restrict your activities to those, which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that it is safe for you to participate in physical activity. “I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.” Please add any additional notes below if required:

Please confirm

I agree to the Terms and Conditions

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