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Breathe Diversity Pilates + Fitness – Santa Rosa, CA
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Breathe Diversity Pilates + Fitness – Santa Rosa, CA

Data Collection Sheet

MM slash DD slash YYYY

General & Medical Questionnaire

Physical Activity Readiness Questionnaire (PAR-Q)

1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?(Required)
2. Do you feel pain in your chest when you perform physical activity?
3. In the past month, have you had chest pain when you were not performing any physical activity?
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
6. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
7. Do you know of any other reason why you should not engage in physical activity?
8. Are you pregnant?

Occupational Questions

2. Does your occupation require extended periods of sitting?
3. Does your occupation require extended periods of repetitive movements? (If yes, please explain.)
4. Does your occupation require you to wear shoes with a heel (dress shoes)?
5. Does your occupation cause you anxiety (mental stress)?

Recreational Questions

6. Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.)
7. Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.)

Medical Questions

8. Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.)
9. Have you ever had any surgeries? (If yes, please explain with dates)
10. Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, diabetes, osteopenia or osteoporosis? (If yes, please explain.)
11. Are you currently taking any medication? (If yes, please list.)
12. Do you practice stress management? (if yes, please explain)
If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
This field is for validation purposes and should be left unchanged.

Breathe Diversity Pilates + Fitness

65 Brookwood Ave, Suite 4
Santa Rosa, CA 95404

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© 2023 Breathe Diversity Pilates + Fitness – Santa Rosa, CA

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  • Appointments and Classes
    • Class Schedule
    • Class Descriptions
    • Book Private Session
    • Gift Cards
  • Rates
  • Studio
    • Get Started In 3 Easy Steps!
    • About Us
    • Our Team
    • Our Studio
    • Join Our Team
    • Testimonials
    • Policies and Procedures
  • Benefits of Pilates
  • Contact Us
  • Account