Online Pilates PARQ – Charlotte Jane

Date of Birth*

Medical Screening Questions

Have you ever suffered from heart trouble?*

Yes
No

Are you presently taking any form of medication?*

Yes
No

If "Yes" please state what for

Do 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 which

Have you ever had asthma, chronic bronchitis or any other chest ailments?*

Yes
No

If "Yes" please state which

Do 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 explain

Have 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 Details

Are 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 Name

Consultant 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.

Date Submitted

User Details

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 correct

How did you find us?

Social Media
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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

Online Pilates Physical Activity Readiness Questionnaire (PARQ)

Medical Screening Questions

Informed consent