Health questionnaire

Welcome to Mindful PIlates - Client information

Making sure we deliver a safe and effective environment for you to reach your goals
Full name *

First Name Last Name

Address *

E-mail *
Birth date
Phone Number *

Area Code Phone Number
Emergency contact *

First Name Last Name
Phone number *

Area Code Phone Number
Clients information - Health questionnaire (Par-Q)
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q *

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel fain in your chest when you do physical activity?
n the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials *

Clear
Client informations - Liability waiver
I am aware of the risks in observing or participating in the activities offered and sponsored by Mindful Pilates Northampton and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death. It is understood that MIndful Pilates Northampton is responsible for any damage that would be resulting from a fault of MIndful Pilates Northampton and its representatives.
Initials *

Clear
Client information - Signature
Signature *

Clear
Date

Jour Mois Année Date Picker Icon
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm