Medical and Lifestyle Questionnaire

First name*

Last name*

Email*

Phone*

Date of Birth*

Address*

Emergency Contact: Name*

Emergency Contact: Phone Number*

Do you have a history of any of the following medical conditions?
EpilepsyHeart problemsMusculoskeletal injuriesNeuromuscular disordersPregnantDiabetesHigh / Low blood pressureArthritisOsteoporosis / OstepeniaChest PainAsthmaDepressionHigh StressOther please detail below

Are you currently taking any medication?
YesNo

Have you ever had any major or minor surgery in the last 10 years?
YesNo

Do you ever or have you ever suffered from back or neck pain?
YesNo

Do you have any other pain or restricted movements in any other joints?
YesNo

Have you ever been diagnosed as hypermobile?
YesNo

Lifestyle

Do you exercise regularly?
YesNo

Which type of classes have you attended?
MatworkAdvanced matworkMachinesHome (DVD)

Have you been referred to Pilates by a specialist practitioner?
GPChiropractorOsteopathPhysiotherapistOther

Do you hereby give us permission to contact your practitioner?
YesNo

I confirm that I have read and understand the full terms and conditions of Shape Pilates. I agree to these terms and conditions.*