Watford Aerobics Network

FP PARQ-Disclaimer Form

Welcome to Watford Aerobics Network Fitness Pilates Classes, please fill out the following Physical Activity Readiness Questionnaire/Disclaimer. All information will be treated confidentially.

Thank you.

*Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No
*Do you ever feel pain in your chest when you do physical activity?
Yes
No
*Have you ever had chest pain when you are not doing physical activity?
Yes
No
*Do you ever feel faint or have spells of dizziness?
Yes
No
*Do you have a joint problem(including back problems) that could be made worse by exercise?
Yes
No
*Have you ever been told you have high blood pressure?
Yes
No
*Are you currently taking any medication of which the Instructor should be made aware?
Yes
No

*Are you pregnant or have you had a baby in the last 6 months?
Yes
No

IF YOU HAVE ANSWERED 'YES' TO ANY OF THE ABOVE QUESTIONS......

Before you can participate in any WAN exercise session, you must be in possession of a note from your GP confirming it is safe for you to participate in this type of exercise and go on to fill out the following Medical Health Questions.

IF YOU HAVE ANSWERED NO TO ALL OF THE QUESTIONS - PLEASE SKIP TO THE LAST STATEMENT.



Have you asked your GP if it is safe for you to take part in group exercise?
Yes
No

INFORMED CONSENT STATEMENT;

I hereby consent to take part in this class at my own risk. If I have any known health problems I will discuss them my instructor. If she offers any reason for not joining in this exercise programme I will adhere to her recommendations. I understand that the risks of undertaking physical activity and exercise may include disorders of heartbeats, abnormal blood pressure response, and, very rarely, a heart attack or death. I further understand that selection and supervision of exercise is a matter of professional judgement. I understand that I can withdraw my consent or discontinue participation in any aspect of the fitness programme at any time without penalty or prejudice toward me. I have read the statement above and have had all of my questions answered to my satisfaction.