Joanna Lewis Pilates / Nordic Walking

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Physical Exercise Readiness Questionnaire

Name *

Address *

eMail Address *

Mobile Phone Number *

Home Phone Number *

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

Yes

Do you experience chest pain brought on by physical activity? *

Yes

Have you experienced any chest pains in the last month? *

Yes

Do you ever lose consciousness or fall due to dizziness? *

Yes

Do you have any bone or joint problems that are aggravated by physical activity? *

Yes

Has a GP ever recommended any medication for high blood pressure or a heart condition? *

Yes

Are you aware through your own experiences or from a GP’s advice of any other reason why you should not exercise without medical supervision *

Yes

Do you have any known allergies *

Pre-existing medical conditions *

Are you currently on any medication *

I understand that my body’s reaction to exercise is not totally predictable. Should I develop a condition that affects my ability to exercise I will inform Joanna Lewis, or her representative, immediately and stop exercising if necessary. *

Agree

Disagree

EMERGENCY CONTACT: Name *

EMERGENCY CONTACT: Phone Number *

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