Physical Activity Readiness Questionnaire • Positive Pilates Group Classes & 1-2-1 Lessons, Ilfracombe

Before taking part in a Positive Pilates class or session, please complete all of the questions below, thank you. It looks daunting however it will take you less than 5 minutes!

When you complete the form, a copy will be emailed to us for our records and we will also email a copy to the address you provide.

You do not need to print the form out and bring it to your first lesson, we will have received an electronic copy that we can refer to.

Your full name:

Gender:

Date of birth (DD / MM / YYYY):

Contact telephone number (mobile is best):

Your full address and postcode:

Your email address:

Where did you hear about us?

Which class do you wish to participate in?

Have you done Pilates before?
If “yes” please can you give us brief details:

Why do you want to do Pilates?

If you attend regular Pilates classes for the next 3–6 months, how do you think this will help you?

If you don’t do Pilates, where do you see yourself in 6 months?

What is your occupation?

What exercise or hobbies do you currently participate in?

Has your doctor ever said that you have a heart condition and recommended only medically supervised activity?

Do you get chest pains brought on by physical activity?

Have you developed chest pains in the last month?

Do you tend to lose consciousness or fall over as a result of dizziness?

Have you had any major surgery in the past, for example a hip replacement?
If “yes” please can you give us brief details:

Have you any form of morbidity, for example Fibromyalgia, MS or ME?
If “yes” please can you give us brief details:

Have you or are you currently suffering with any neck or spinal issues, for example Sciatica?
If “yes” please can you give us brief details:

Do you have a bone or joint problem that could be aggravated by the proposed physical activity?
If “yes” please can you give us brief details:

Has a doctor ever recommended medication for your blood pressure or heart condition?
If “yes” please can you give us brief details:

Are you pregnant or have you had a baby in the last 12 weeks?
Gents, you can obviously ignore this one!

Are there any other medical, physical or mental conditions not mentioned above that we should be aware of?
If “yes” please can you give us brief details:

Have you visited a Physio, Chiropractor or Osteopath in the last 12 months?
If “yes” please can you give us their name and address:

We will not contact them without your prior written consent.

If you have answered Yes to any of the above questions, then you may be required to gain consent from your doctor before participating in a Pilates session. Positive Pilates will contact you if this consent is required.

Informed consent to take part in Positive Pilates classes.
I have read, understood and answered honestly the Physical Activity Readiness Questionnaire above and the information I have given is correct to the best of my knowledge. Whilst every effort is made to keep the class safe and enjoyable, I am participating of my own free will and as with any exercise programme I understand there is a risk of injury. I understand that on occasions there may be a stand-in-instructor. I understand there may be times when the instructor may need to use hands-on adjusting to help you into the correct position or form during an exercise and I consent to be assisted as required.

Data Protection
I consent to Positive Pilates processing and storing all the information and data supplied via this form. I understand my contact details and the data collected from this form will only be used by Positive Pilates to respond to my enquiry and will not be shared with any third parties without my written consent. Your details will not be added to any email marketing list nor will they be sold onto third parties. Positive Pilates will securely store the information and you can request a copy of it by contacting us. To ensure our insurance is valid we need to store the details from this form for at least x3 years from the date of supply. You can request we delete any information we store about you at anytime. However if you do request we delete your details, then Positive Pilates will not be able to provide instruction and you will not be able to participate in our classes. Your data may be stored outside the EEA (European Economic Area).

Yes I consent

Lesson and Offers Terms & Conditions
I have read and understood Positive Pilates’ Lessons and Offers Terms & Conditions and I agree to be bound by them.

Today’s date (DD / MM / YYYY):

All the details you supply in this form are confidential to Positive Pilates and will not be added to any emailing list or passed on or sold to anyone else. The information you provide will only be used to assist us when teaching you in classes we provide. Positive Pilates will securely store the information and you can request a copy of it by contacting us. You can also request we delete any information we store about you. However if you do request we delete your details, then Positive Pilates will not be able to provide instruction and you will not be able to participate in our classes. Please note that we do not require any help with SEO or web design or marketing and so forth. All such requests will be ignored.

Bev Grant
Positive Pilates
53 High Street
Ilfracombe
North Devon
EX34 9QB

Mobile: 07917 762227
Monday to Friday, 10am – 5pm