Physical Activity Readiness Questionnaire Email First Name * Last Name * DOB: * Email Address * Mobile: Telephone: Home Address * Postcode * Many health benefits are associated with regular exercise and the completion of this questionnaire is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people this should not pose a problem or a risk. Please read the questions below carefully and click YES/NO to each question as it applies to you. Do you have any of the following? Please provide further details at the bottom of the form if you answer YES to a medical condition and provide details of medications which you are currently taking Diabetes YesNo Epilepsy YesNo Asthma YesNo High Blood Pressure YesNo A Heart Condition YesNo Frequent Chest Pains YesNo Joint Problems - e.g. Spine, Knees YesNo Surgery in the last 6 months YesNo Do you suffer from fainting or dizziness? YesNo Are you taking any prescribed medicine which may affect your physical abilities? YesNo Do you exercise regularly? YesNo Is there anything which may affect your participation in exercise? (e.g. recently had a baby or pregnant?) YesNo Data Protection (GDPR) Act 2018 Please Tick the boxes to agree I agree that my details can be retained for up to a year, prior to being updated or destroyed Yes The class may occasionally be photographed /filmed for Social Media and Advertising purposes. No names or locations are disclosed without your prior consent. Yes I agree to receiving communications to keep me informed of class news and updates Yes Next of kin In the event of an emergency I would wish the following person to be notified: Name Contact number Medical Conditions Medication Details (only medicines which might affect your ability to exercise) IMPORTANT: Before you start the class you must ensure: YOU have checked the area where YOU are working and have made sure there are no obstacles or hazards YOU are fit and well enough to complete the class and advised the Instructor of any medical conditions, which are not already declared (ParQ) Any equipment used by the YOU is being used correctly, in line with the manufacturer’s guidelines. YOU must be a UK resident and taking part within the UK The Instructor accepts no liability for any accident or injury resulting from participating in activities if the above conditions have not been met. By submitting this form your consent is given. Irene Gibson Pilates Instructor & Personal Trainer 75 Vicarage Road Buntingford SG9 9BA M: 07802 418755 E: ig@irenegibson.co.uk For the latest updates and class news follow me on Facebook FollowFollow