EmailMe Form - Physical Activity Readiness Questionnaire (PAR-Q)

I would like to register for the following class

Name *

First Last

Email *

Date of birth *

MM / DD / YYYY

Have you practiced yoga before? Please give details of how long, what style of yoga etc. *

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

Has your doctor ever said that you have a bone/joint problem, such as arthritis, that might be, aggravated by exercise? *

Yes

No

Do you feel pain in your chest when you do physical activity? *

Yes

No

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

In the past month, have you had a chest pain when you were not doing physical activity? *

Yes

No

Do you lose you balance because of dizziness or do you ever lose conciousness? *

Yes

No

Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity? *

Yes

No

Is your doctor currently prescribing medication for your blood pressure or heart condition? *

Yes

No

Do you know of any other reason why you should not do physical activity? *

Yes

No

If yes, please do let me know why

I have read, understood and accurately completed this questionnaire. *

Yes

No

I , the above named participant, understand that all practices are optional; I hereby waive any and all claims I have now or in the future against Soul Space and my teacher.

I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

I take full responsibility for my body and if I have any doubts I will seek the advise of a medical professional before attending the class. *

I agree

I disagree

Where did you hear about this class?