Par-Q Form

Name

Date of birth

Email *

Phone

Class participation

Where did you hear about Georgina Kay Yoga and Pilates?

Health screening

Has your doctor ever said that you have a heart condition and that you should only do physical activity when recommended by a doctor?

Yes
No

Do you feel pain in your chest when you do physical activity?

Yes
No

In the past month have you had a chest pain when you were not doing physical activity?

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes
No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? If you answer yes you are advised to seek advice from a health care professional first. See declaration below

Yes
No

Is your doctor currently prescribing you drugs for blood pressure or a heart condition? If you answer yes you are advised to seek advice from a health care professional first. See declaration below

Yes
No

Are you pregnant or have you had a baby in the last 8 weeks?

Yes
No

Is there any other reason why you should not participate in physical activity or anything I should know?

If you answered yes to one or more questions

You should talk to your doctor by phone or in person before you start becoming more physically active. Tell your doctor about the questionnaire and which questions you answered YES to. Please also tell your instructor, if you have already got medical clearance for Yoga/Pilates or moderate exercise in general, please fill in the declaration below. If your health changes so that you answer YES to any of the above, please inform your teacher. By submitting this booking form, you have asked to receive emails and communications from us. This will keep you informed on updates. You can unsubscribe at any time. This is following General Data Protection Regulations (GDPR) 25th May 2018. By signing & submitting this booking form you confirm you have read and understood this questionnaire. If you have any concerns, contact us by email and ensure you speak with your instructor at the start of your class.

Declaration

This applies if you have answered yes or no to any of the above questions. I declare I have been cleared by my doctor (GP, specialist or other qualified health professional) to take part in moderate exercise. Please submit this form to indicate your informed consent.

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Health screening

If you answered yes to one or more questions

Declaration