If you are planning to take part in physical activity or an exercise class and you are new to exercise, start by answering the questions below. If you are between the ages of 15 and 69 the questionnaire will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.
If you answer Yes to any questions please write a brief explanation.
YOUR INSTRUCTOR WILL TREAT ALL INFORMATION CONFIDENTIALLY.
Please Circle
| Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? | yes | no |
| Do you ever feel pain in your chest when you do physical activity? | yes | no |
| Have you ever had chest pain when you are not doing physical activity? | yes | no |
| Do you ever feel faint or have spells of dizziness? | yes | no |
| Do you have a joint problem that could be made worse by exercise? | yes | no |
| Have you ever been told that you have high blood pressure? | yes | no |
| Are you currently taking any medication of which the instructor should be made aware? | yes | no |
| Are you pregnant or have you had a baby in the last 6 months? | yes | no |
| Is there any other reason why you should not participate in physical activity? | yes | no |
IF YOU HAVE ANSWERED YES TO ONE OR MORE QUESTIONS
Talk to your doctor by phone or in person before you start becoming more physically active and before you start on this course. Tell your doctor about the questionnaire and which question you answered YES to.
You may be able to do this Pilates course - as long as you build up slowly and gradually. Or you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activity you wish to participate in and follow his/her advice.
IF YOU HAVE ANSWERED NO TO ALL QUESTIONS
You can be reasonably sure that you can start to become more physically active and take part in this Pilates course. Remember to begin slowly and build up gradually.
PLEASE NOTE
If your health changes so that subsequently you answer YES to any of the above questions, inform the instructor immediately. If you feel unwell because of a temporary illness such as cold or flu - delay becoming more active and wait until you are better.
WHAT ARE YOUR MOTIVES FOR EXERCISING?
I HAVE READ, UNDERSTOOD AND COMPLETED THIS QUESTIONNAIRE
Name:
Signature:
Date:
Emergency contact name and phone no: