PAR-Q health form

20%

Name
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Email
Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Your Height
Your Weight

1. Do you have any injuries, aches or pains? (Recent or Old) Please describe them:
2. Do you have any other health concerns? E.g. asthma, diabetes, high blood pressure, or any condition for which you take medications
3. Are you presently doing any other kinds of therapy? E.g. massage, physio, chiropractic
4. Are you or were you involved in any sport or exercise programme, physical activity?
5. Have you had any past training in the Pilates or yoga method of movement? If yes, where?
6. What is your occupation?
7. How did you hear about Fitness Ways?

8. Do you suffer from osteo/rheumatoid arthritis? If so which joints are affected?
9. Do you have any problems with your bones? (Osteoporosis or height loss)
10. Have you any back problems?
11. Can you get down to the floor unaided?
- Yes
- No
12. Is there any other information you feel the instructor would benefit from knowing?

13. Are you taking any medication? If so, for which conditions is the medication to treat?
Health Conditions Medications
14. Are you currently in employment?
- Yes
- No
15. What is your occupation?
16. How stressed are you? On a scale of 1-10 where 1 is Not at all stressed, identify a number which represents how you feel.
17. How healthy is your current diet. On a scale of 1-10 where 1 is very healthy, identify a number which represents how healthy you currently feel.
18. What is your current physical activity level? How many minute/hours a week are you active? What intensity do you achieve whilst being active?
19. What is your preferred physical activity?
20. Do you have any current pelvic health issues? (Pelvic girdle or musculature)

Health Conditions	Medications