PAR-Q HEALTH FORM | Wild Within

Welcome to Wild Within yoga. Please take a few minutes to complete this short health questionnaire.

Your answers help ensure that sessions are safe, supportive, and adapted to your individual needs.

All information is kept confidential and used only to support your well-being during practice.

Section1 of 5

Email

First name

Last name

Date of Birth

Day

Month

Year

Phone Number

Emergency Contact Phone Number

Section 2 of 5

General Health

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

Yes

No

Do you feel pain in your chest when doing physical activity?

Yes

No

Other

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

Yes

No

Do you lose balance because of dizziness or lose consciousness?

Yes

No

Do you have any bone, joint, or back problems that could be made worse by exercise?

Yes

No

Are you currently taking any prescribed medication that may affect your ability to exercise?

Yes

No

Do you know of any other reason why you should not take part in physical activity?

Yes

No

If you answered YES to any of the above, please provide details:

Section 3 of 5

Current Health and Lifestyle

Are you currently pregnant or have you recently given birth?

Yes

No

Do you suffer from high or low blood pressure?

Yes

No

Do you have asthma or breathing difficulties?

Yes

No

Do you have any injuries, chronic pain, or limited mobility?

Yes

No

Please list Injuries and how these may affect mobility:

Please list any other relevant health conditions (e.g. anxiety, arthritis, recent surgery, medical diagnosis):

Do you suffer from any allergies (including food or anything else)?

Yes

No

If yes, please list below

Section 4 of 5

Informed Consent

Please read and confirm the following statement: I confirm that the information I have provided is correct to the best of my knowledge. I understand that yoga involves physical movement and carries some risk of injury. I am responsible for listening to my body and practicing within my own limits. I agree to inform the instructor of any health changes before future sessions. I understand that Wild Within and its instructors are not liable for any injury sustained during participation.

Please type your full name as a digital signature to confirm consent:

Date

Day

Month

Year

Section 5 of 5

Optional Consent

I consent to being contacted by Wild Within about future classes, retreats, or events.

I consent to photos or videos taken during classes being used for Wild Within marketing (optional).

PAR-Q & Health Declaration Form