General Health Form

Please read and complete the following questions as fully as you can. All details given on this form will be kept in the strictest confidence.

Client Information

Name

First Name

Last Name

Date of Birth

YYYY

Telephone Number

Exercise Experience / Fitness Level

Why do you want to start a pilates practice? What are your aims and expectations from the session/class?

General Health Questions

Please read through the below list of health conditions. Please indicate in the box below if any of them are applicable in your case (add anything else that you might think is relevant). If none of the above apply, please state so.

High/Low Blood Pressure, Arthritis, Joint Problems, Back Problems, Neck/Shoulder Problems, Respiratory Problems, Diabetes, Epilepsy, Neurological Conditions, Dizziness and Fainting, Stroke, Heart Conditions, etc. Injuries or operations in the last year. Any medication that might impact my ability to exercise.

WOMEN ONLY: Are you or have you been pregnant in the last 18 months?

Yes

Emergency Contact Details

Emergency Contact Person

First Name

Last Name

Emergency Contact Phone Number

I have completed this questionnaire to the best of my knowledge and I have not withheld information that may be significant or relevant. I undertake to advise of any significant changes to my health and present condition, including health and surgery. I understand that all exercise carries a risk of injury. I accept responsibility for my own body and stop exercising if I need to. I consent to exercising on my own risk. I understand that Pilates exercises involve hands on correction and I hereby give consent for my teacher to work in this way.

By pressing SUBMIT I confirm that I have read and understood the above advise and that the information I have given is correct.

General Health Form

General Health Form

Pilates Generations