QUESTIONNAIRE

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

Please fill in the form below before participating in any of the sessions:

Please Indicate: Name, DOB, Email, Contact

1. Have you had any operations in the last 12 months?

No

Yes

2. Do you have a history of heart problems or chest pain when exercising?

No

Yes

3. Do you have any joint problems or back complaints?

No

Yes

4. Are you currently pregnant or have you given birth in the last 6 months?

No

Yes

5. Do you have any breathing difficulties or asthma?

No

Yes

6. Do you suffer from high or low blood pressure?

No

Yes

7. Are you taking any medications?

No

Yes

8. Are there any other medical conditions, injuries or illnesses that you suffer from? Please list?

No

Yes

9. If you have answered ‘YES’ to any of the above, please provide details.

PLEASE NOTE: By participating in any of the Pilates Fusion Live and Online sessions, and using any of the library material, you are doing it at your own RISK. Pilates Fusion (Cheryl Chidrawi) will not be held responsible for any damage or injuries caused by your participation.

Please consult with your doctor before signing up to any of the sessions.

Thanks for submitting!