Pilates Training Registration and PAR-Q+ Δ
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Other Area of Focus Details
Areas of Focus Priority
If you have several choices for areas of focus, please rank them in order of priority in this field.
Preferred Days and Times for Training Sessions
Have you ever done Pilates reformer before? Or mat Pilates? Please specify.
Release and Waiver Agreement
By checking this box, participant acknowledges the activity contains risks and agrees to the Release and Waiver language from the registration packet.
APEX PRD PAR-Q+ The Physical Activity Readiness Questionnaire for Everyone Participating in physical activity is very safe for most people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor or a qualified exercise professional before becoming more physically active.
Has your doctor ever said that you have a heart condition OR high blood pressure?
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
Have you ever been diagnosed with another chronic medical condition other than heart disease or high blood pressure?
Are you currently taking prescribed medications for a chronic medical condition?
Do you currently have, or have had within the past 12 months, a bone, joint, or soft tissue problem that could be made worse by becoming more physically active?
Has your doctor ever said that you should only do medically supervised physical activity?
Please list any conditions and/or medications mentioned above
Follow-Up Questions About Your Medical Conditions
Do you have arthritis, osteoporosis, or back problems?
Do you have difficulty controlling your arthritis, osteoporosis, or back condition with medications or other physician-prescribed therapies?
Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?
Have you had steroid injections or taken steroid tablets regularly for more than 3 months?
Do you currently have cancer of any kind?
Does your cancer diagnosis include lung/bronchogenic, multiple myeloma, head, and/or neck cancer?
Are you currently receiving cancer therapy such as chemotherapy or radiotherapy?
Do you have a heart or cardiovascular condition, including coronary artery disease, heart failure, or diagnosed abnormal heart rhythm?
Do you have difficulty controlling your heart/cardiovascular condition with medications or other physician-prescribed therapies?
Do you have an irregular heartbeat that requires medical management?
Do you have chronic heart failure?
Do you have diagnosed coronary artery disease and have not participated in regular physical activity in the last 2 months?
Do you currently have high blood pressure?
Do you have difficulty controlling your high blood pressure with medications or other physician-prescribed therapies?
Do you have a resting blood pressure equal to or greater than 160/90 mm Hg with or without medication, or do you not know your resting blood pressure?
Do you have any metabolic conditions, including type 1 diabetes, type 2 diabetes, or pre-diabetes?
Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?
Do you often suffer from signs and symptoms of low blood sugar following exercise and/or during activities of daily living?
Do you have signs or symptoms of diabetes complications involving heart/vascular disease, eyes, kidneys, toes, or feet?
Do you have other metabolic conditions such as current pregnancy-related diabetes, chronic kidney disease, or liver problems?
Are you planning to engage in unusually high or vigorous intensity exercise in the near future?
Do you have any mental health problems or learning difficulties?
Do you have difficulty controlling your mental health or learning condition with medications or other physician-prescribed therapies?
Do you have Down Syndrome AND back problems affecting nerves or muscles?
Do you have a respiratory disease, including chronic obstructive pulmonary disease (COPD), asthma, or pulmonary high blood pressure?
Do you have difficulty controlling your respiratory condition with medications or other physician-prescribed therapies?
Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?
If asthmatic, do you currently have symptoms of chest tightness, wheezing, labored breathing, consistent cough, or have you used rescue medication more than twice in the last week?
Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?
Do you have a spinal cord injury, including tetraplegia or paraplegia?
Do you have difficulty controlling your spinal cord injury condition with medications or other physician-prescribed therapies?
Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?
Has your physician indicated that you exhibit sudden bouts of high blood pressure known as autonomic dysreflexia?
Have you had a stroke, transient ischemic attack, or cerebrovascular event?
Do you have difficulty controlling your stroke-related condition with medications or other physician-prescribed therapies?
Do you have any impairment in walking or mobility?
Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?
Do you have any other medical condition not listed above or do you have two or more medical conditions?
Have you experienced a blackout, fainted, lost consciousness as a result of a head injury within the last 12 months, or had a diagnosed concussion within the last 12 months?
Do you have a medical condition that is not listed, such as epilepsy, neurological conditions, or kidney problems?
Do you currently live with two or more medical conditions?
Please list your medical conditions and any related medications
Participant Declaration If you answered NO to all of the follow-up questions about your medical condition, you are ready to become more physically active. Please sign the Participant Declaration.
It is advised that you consult a qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs. You are encouraged to start slowly and build up gradually with any aerobic or muscle strengthening exercises. As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you answered YES to one or more of the follow-up questions about your medical condition: You should seek further information before becoming more physically active or engaging in a fitness program. You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted. Apex Park and Recreation District does not assume liability for persons who undertake physical activity and/or make use of the Apex PRD PAR-Q+. If in doubt after completing the questionnaire, consult your doctor prior to physical activity. All persons who have completed the PAR-Q+ please read and sign the declaration below. If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form. I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for the length of my training sessions and becomes invalid if my condition changes. I also acknowledge that Apex Park and Recreation District may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.
Participant Declaration Agreement
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