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Physical Activity Readiness Questionnaire

Please provide the following details to allow us to assess your readiness to exercise.

First name

Last name

Email

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Is there a history of chronic heart disease in your family? *

Yes

No

Are you pregnant or have you been pregnant recently? *

Yes

No

Do you have any children? *

Yes

No

What are your children's ages?

Are you taking any medication? *

Yes

No

What medication are you taking?

Have you ever suffered from any of the following?

High Blood Pressure Regular Headaches Diabetes

Female Hormone Problems

Heart Problems

Back Pain

Chest Pains in Last 2 Weeks

Sports Injury Asthma

None of the above

If yes, give brief details

Have you had any fractures? *

Yes

No

Do you get any joint aches or pains?

Neck

Shoulder

Back

Knee

Hip

Ankle

Other

List any current or past injuries

Any other complaints or injuries that may affect your ability to exercise?

Have you ever tried Pilates before? *

Yes

No

Where and how regularly?

I declare that the info I’ve provided is accurate & complete

I confirm that I am participating in training with energyflowfitness voluntarily and I am aware that I can discuss my participation with my doctor before continuing.

It is understood that I have not undergone a complete medical examination but have represented to the trainer all physical disabilities, medical conditions, and medication. The trainer relies solely on the representations made by the client.

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EnergyFlowFitness

40 High Lane
Chorlton
Manchester M21 9DZ

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