The Physical Activity Readiness Questionnaire: PAR-Q
For most people physical activity should not pose any problem or hazard. PAR-Q has
been designed to identify the small number of adults for whom physical activity might be
inappropriate or those who should have medical advice concerning the type of activity
most suitable for them.
Common sense is your best guide in answering these few questions. Please read them
carefully and circle the yes or no opposite the question it if applies to you.
yes   no    1. Has your doctor ever said that you have heart trouble?  
yes   no    2. Do you frequently have pains in your heart or chest?
yes   no    3. Do you often feel faint or have spells of severe dizziness?
yes   no    4. Has a doctor ever said that your blood pressure was too high?
yes   no    5. Has your doctor ever told you that you have a bone or joint problem
such as arthritis that has been aggravated by exercise, or might be made worse with exercise?
yes   no    6. Is there a good physical reason not mentioned here why you should not
follow an activity program even if you wanted to?
yes   no    7. Are you over the age of 65 and not accustomed to vigorous exercise?

yes no. 8. Are you, or were you recently pregnant?
If you answered YES to one or more of these questions… if you have not recently done
so, consult with your personal physician by telephone or in person before increasing your physical activity and/or taking a fitness test.
If you answered NO to all questions… if you answered PAR-Q accurately, you have
reasonable assurance of your present suitability to start an exercise program and/or to
take an exercise test.
Note: If you health changes so that you then answer YES to any of the above
questions, ask for advice from your fitness or health professional.

Name (please print) __________________________________
Telephone number _______________________________

Signature _____________________________ Date _____________________
This agreement affects your legal rights. Read it carefully!
You, the participant/member, are aware that there are risks associated with
participating in fitness activities and exercise. Your participation is completely
voluntary, and you freely accept and fully assume all responsibility for all risks, and all possibilities of personal injury, death, property damage or loss to yourself or any other person as a result of your participation in fitness activities. You and your heirs, next of kin, executors, administrators and assigns agree:  
a) To wave all claims, known or unknown, that you have or may have in the future
against Pilates with Samantha, including their owner, officers, directors, agents,
employees, volunteers, business operators, independent contractors and site property
owners or lessees:
b) that Pilates with Samantha is not liable or responsible for any damage to, loss of or theft
of property;
c) to release and forever discharge Pilates with Samantha from all liability for any personal
injury, death, property damage or loss resulting from your participation in fitness
activities due to any cause, including but not limited to negligence (failure to use such
care as a reasonably prudent and careful person would use under similar circumstances), breach of any duty imposed by law, breach of contract or mistake in error or judgment of Pilates with Samantha; and
d) to be liable for and to hold harmless and indemnify Pilates with Samantha from all actions, proceedings, claims, damages, costs demands, including court costs on a solicitor and own client basis, and liabilities of whatsoever nature of kind arising out of or in any way
connected with your participation in fitness activities.
Please consult your physician prior to starting an exercise or fitness program, and prior to participating in classes or using the facility
___________________________________ the participant/member has read,
(print name)
understood and agrees to all of the above statements.
Signed _________________________________

Date __________________________


Samantha Clayton
PMA-Certified Pilates Instructor
Pink-Ribbon Certified