New Health Form – Pilates4Living

Pilates4Living

Pilates4Living

Health Form

First Name *

Last Name *

Email *

Phone *

Year You Were Born

to Repeater do

Contact's Name

Contact's Phone Number

Have you had surgery in the last 10 years? *

Surgery History

If you answered YES, please give brief details

Have you suffered, or do you suffer, from any of the following?

If you have ticked any of the above, please provide details

Are you pregnant? *

If YES, when is your baby expected?

Please outline any other conditions which may affect your ability to exercise

Your Occupation

How frequently do you exercise?

What type of exercise?

Declaration *

I acknowledge that I am fully responsible for monitoring my capability to participate in any exercise session, that I will advise Pilates4Living of any health or medical conditions that may affect my participation. I also acknowledge that I have answered the questions accurately and to the best of my ability and that I understand the contents of this questionnaire.

Date *

Pilates4Living
The Place, Melrose Street
Sherwood, Nottingham
NG5 2JP

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