Name *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact Phone

(###)

###

####

First time trying Pilates?

Yes

No

If YES, how many classes have you previously attended?

0-10

10-20

20+

Are you, or could you be, pregnant?

Yes

No

Have you been pregnant in the last 6 months?

Yes

No

Has your doctor ever told you that you have any kind of heart trouble or defect?

Yes

No

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

Yes

No

Do you often get headaches?

Yes

No

Do you lose your balance because of dizziness? Or do you ever feel faint or dizzy?

Yes

No

Do you have high blood pressure?

Yes

No

If NO, is your blood pressure:

Normal

Low

Do you suffer from asthma, diabetes or epilepsy?

Yes

No

Have you had any major surgery in the last 15 years?

Yes

No

Have you had any minor surgery in the last 5 years?

Yes

No

Have you ever been told that you have:

Osteoarthritis?

Rheumatoid Arthritis?

Osteoporosis?

Osteopoenia?

Other joint problems?

Have you ever been diagnosed as hypermobile?

Yes

No

Do you suffer from back or neck pain?

Yes

No