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PAR Q Form

First name

Last name

Date of Birth

Have you been hospitalised in the last 12 months

Yes

Have you or do you currently experience a shortness of breath or heart conditions that affect physical activity.

Yes

Have you experience any dizziness or loss of consciousness when you do physical activity in the last 12 months

Yes

Have you any diagnosed illness that could bemade worse by physical activity.

Yes

Are you taking any medication perscribed or otherwise

Yes

Do you have any diagnosed illness that could be made worse by physical activity

Yes

Are you suffering from any medical condition, illness or injury

Yes

In the last 6 months have you been pregnant

Yes

Please specify anything we should know about

Initials

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

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program. Note: Brusing my occur due to the nature of pole fitness. Physical spottig will takeplace during classes and photos can be taken for social meda purposes.

Thanks for submitting!

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