PAR-Q
Step 1 of 7
Village Fit · Michelle Mark

Client Intake Form

Please complete all sections before your first session. All information is kept strictly confidential.

Step 1 of 7

Physical Activity Readiness

PAR-Q — Please answer honestly. For ages 15–69.

QuestionYesNo
1. Has your doctor ever said you have a heart condition and should only do physical activity recommended by a doctor?
2. Do you feel pain in your chest when you do physical activity?
3. In the past month, have you had chest pain when not doing physical activity?
4. Do you lose your balance because of dizziness or 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 drugs (e.g., water pills) for blood pressure or a heart condition?
7. Do you know of any other reason why you should not do physical activity?

If you answered YES to any question, speak with your doctor before becoming much more physically active. Clearance is valid for 12 months.

Step 2 of 7

Informed Consent & Release

I have enrolled in a movement therapy with Michelle Mark and affirm I am in good physical condition without disability that would limit my participation.

I hereby release Michelle Mark from any claims arising from my participation, including but not limited to heart attacks, strokes, muscle strains, broken bones, shin splints, heat injury, and joint injuries. I am aware these injuries may occur even though all parties will take care to avoid them. I will inform Michelle if any problems arise and may withdraw consent at any time.

1. Purpose & Procedure

I consent to voluntarily engage in private or group activity and follow staff instructions. I expressly consent to physical contact for proper technique and body alignment assessment.

2. Risks

I understand the remote possibility of adverse changes including abnormal blood pressure, fainting, dizziness, and very rare instances of heart attack or stroke. Knowing these risks, I desire to participate.

3. Confidentiality

All information is privileged and confidential and will not be released without my express written consent, except for consultation with other health professionals.

Step 3 of 7

Cancellation & Policies

Read each policy and click the INITIAL tab to confirm your agreement.

Step 4 of 7

Medical Background

Please answer Yes or No to each health history question.

ConditionYesNo

If you answered "yes" to any of the first six questions — please see your physician before starting physical activity.

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Step 5 of 7

Lifestyle Questionnaire

The more detail you provide, the better we can serve you.

Step 6 of 7

Goals & Additional Information

e.g. learning hypopressives, decreasing pain, improving core strength

Postpartum Questions (if applicable)

Step 7 of 7

Review & Submit

Please add your final signature to confirm all information.

By signing and submitting this form, I confirm that I have read, understood, and completed all sections truthfully and to the best of my knowledge.

Note: Initialed policies must also be confirmed in-person with Michelle before your first session.

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Thank you!

Your intake form has been submitted. Michelle will be in touch before your first session.