Is it OK to add your e-mail to my newsletter list? Please note that I will not pass your e-mail address on. *

Name: *

Phone Number: *

Address: *

Date of Birth *

Emergency Contact Name & number *

Has your doctor ever said you have heart trouble? *

Do you frequently have pains in your heart or chest *

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

Do you have a bone or joint problem that could be or has been aggravated by exercise? *

Has your doctor ever recommended medication for blood pressure or heart condition? *

Are you aware, through your own experience or a doctors advice, of any other physical reason against your exercising without medical supervision? If YES, please add details to the bottom of this form. *

Are you over the age of 65 and not accustomed to vigorous exercise? *

Are you currently pregnant, or have been pregnant within the last 6 months? *

Have you consulted with your physician regarding increasing your physical activity and/or performing a fitness assessment?

If you answered NO to question 9, will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?

Do you currently exercise? If yes, what do you do & how many hours per week?

Injuries to pelvic area (inc radiotherapy, episiotomy, etc)

Do you have a chronic cough or sneeze (hayfever, asthma, smoker)

Do you suffer with constipation (IBS/Crohns/IBD/Other)

Overweight BMI over 25

Do you leak urine on exercise, cough, laugh etc?

Constantly need to go to the toilet

Find it difficult to empty your bladder or bowel (or just feel unfinished)

Accidentally lose control of bowel

Do you have a prolapse (feeling of heaviness, dropping or bulge)

Pelvic pain or pain with intercourse

Do you have any prostate issues?

Have a Diastsis Recti (Ab Separation)? If yes, what size is it?

Have you seen a Women's Health Physio or other Specialist?

Number of pregnancies

Menopause

Have you had any gynaecological surgery?

Please tick any of the following that apply to you, further details can be provided in the box below.

Any Further Details:

COVID-19 (Coronavirus) - The health and safety of myself and my clients are always my number one priority. Due to the recent coronavirus outbreak and in line with government advice, if you are, self-isolating, experiencing or displaying any symptoms (high temperature/new, continuous cough/loss or change to your sense of smell or taste ) of coronavirus or have knowingly come in to contact with anyone who has, I ask that you inform me & DO NOT attend your in-person session. If you do experience or display any symptoms of coronavirus and have attended the studio within the previous 14 days I ask that you inform me immediately so that I can take any necessary precautions. *

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury. I will work at an appropriate level for myself and stop if I feel pain or discomfort and inform my instructor. This PAR-Q is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes. It is your responsibility to inform the instructor about any changes in your health. *