Online Pilates PARQ Online Pilates Physical Activity Readiness Questionnaire (PARQ) Please fill in this online medical form. Make sure you answer all the questions correctly, we need to ensure the programme is suitable for you. Date of Birth* DD slash MM slash YYYY Medical Screening QuestionsHave you ever suffered from heart trouble?* Yes No Are you presently taking any form of medication?* Yes No If "Yes" please state what forDo you suffer from chest pains?* Yes No Do you ever have spells of dizziness or feel faint?* Yes No Have you ever had either high or low blood pressure?* Yes No Have you ever had high cholesterol levels?* Yes No Do you suffer from back pain or any orthopaedic problem?* Yes No If "Yes" please state whichHave you ever had asthma, chronic bronchitis or any other chest ailments?* Yes No If "Yes" please state whichDo you suffer from severe headaches or migraines?* Yes No Are you recuperating from a recent illness/operation or injury?* Yes No If "Yes" please state explainHave you ever suffered from diabetes? Including gestational diabetes:* Yes No Do you suffer from any other conditions that may affect your participation?* Yes No If Yes Please Give DetailsAre you pregnant?* Yes No If "Yes" how many weeks?Is there any history of heart disease in your immediate family? (Under the age of 55)* Yes No Are you currently suffering with any forms of incontinence?* Yes No Have you ever had a prolapse?* Yes No Have you currently got a prolapse?* Yes No Do you know of any other reason that could affect your participation?* Yes No If you answered YES to any of the questions you must seek medical advice/approval before commencing any of our exercise programmes. I have been informed that if I answer "YES" to any of the questions of this questionnaire, I must seek medical advice/approval before commencing any of the online exercise programmes. If I wish to continue without such advice I do so entirely at my own risk. I confirm that I have read, fully understood and answered the above questions honestly. I understand that Fitness Pro 24 7 Ltd. cannot be held responsible for any injuries or ill health arising from my participation in the exercise programme. GP/Consultant approved if any of the answers were "yes":* Yes No Signed* Enter Your Full NameConsultant Name Informed consent An online Pilates programme has been designed for you, taking into account varying health and fitness levels. It will involve core stability, strength and endurance exercises. The programme also aims to help you to improve your posture, while the exercises will help to place you in the correct position, it is important for you to understand that this doesn’t mean that it will automatically correct your posture. All exercises will be demonstrated and explained and there are PDF versions of each workout in case you prefer to study the workout before you follow the video or learn certain exercises at a slower pace. There is an element of risk with any exercise programme, this programme has been designed to minimise the risk and maximise the training benefit to assist you in achieving your goals. If at any time during a workout you feel excessive pain or discomfort, you should stop exercising. You should only start again when you are no longer feeling any pain or discomfort. If you are unsure at any point whether you should be taking part in the programme then you should seek medical approval. It is very important that you complete the warm up and set up before each workout and the stretch at the end of each workout. This will help to reduce the risk of injury, it will ensure that you have had the opportunity to start the workout with the correct posture and that you have been able to practise engaging your core muscles. Completing the full body stretch can also help to reduce your risk of injury as it may help to prevent your muscles from getting too tight. It will also make you aware of any areas of the body which may feel a bit stiff and therefore, give you the opportunity to focus on that area. The stretch should also help you to feel more relaxed. I agree to take part in Charlotte Jane’s Pilates programme, I understand that the programme will change and progress over the weeks. The nature, purpose, risks and benefits have been fully explained to me. I warrant that I have made a full and correct disclosure of my health status on the Medical Screening Questionnaire, that my status has not changed. I am not aware of any adverse medical conditions that I would be expected to state. I understand that Fitness Pro 24 7 Ltd does not bear any liability for personal injury however caused to any persons including but not limited to myself as a result of my participation in this programme. It is important for you to be aware that the online Pilates programs are NOT suitable for anyone who is currently suffering with pelvic floor problems, including incontinence or prolapse. If you have had either of these conditions it is extremely important to seek appropriate medical advice and get a referral to a specialist. Fitness Pro does offer pelvic health workshops which may be suitable, please contact us for more information. If you continue with the exercises knowing that they are not suitable, you do so entirely at your own risk. HiddenDate Submitted HiddenUser DetailsUsername: Login: First Name: Surname: User ID: Email: Consent* I agree to Fitness Pro’s consent form and confirm that all answer are correct:By checking this box you agree to Fitness Pro’s consent form and confirm that all answer are correctHow did you find us? Social Media Google Search Link from another website Word of mouth Current client It is important to seek medical advice if you have answered YES to any of the questions. If you have any concerns please email me at info@charlotte-jane.co.uk
