Health Questionnaire — My Pilates m.o

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile number

Home number

Email Address

D.O.B

YYYY

Emergency Contact

First Name

Last Name

Emergency Contact

Name, relationship, contact number

I am happy for you to contact me when necessary by the following methods

Mobile

Home phone

Please give details including dates, medical treatment received and medications taken

Have you had surgery in the past year?

Yes

Are you currently under the care of a health professional? Doctor, Consultant, Physiotherapist etc

Please give details

Have you ever been advised to avoid physical activity?

Please give details

Do you have any medical conditions that could be made worse by physical activity?

Yes

Pregnancy Related Questions

Are you currently pregnant?

Yes

If yes has your Midwife or other Medical professional given you the all clear to participate in physical activity?

Yes

Have you been pregnant in the past?

Please give details of previous pregnancies, miscarriages and deliveries.

Have you experienced pregnancy related muscle/joint problems?

Yes

Did you exercise regularly before pregnancy?

What did you do?

Is there anything else you can think of that may affect you attending Pilates sessions?

If yes, please provide details

I declare the information I have provided is true and I understand that if I have given false information or neglected to inform My Pilates M.O. of anything that may affect my ability to participate in Pilates I am fully responsible. If my health changes at any point I will inform My Pilates M.O. as soon as possible. I confirm that I am voluntarily participating in activities agreed with My Pilates M.O. and that participation does carry risk of injury. I agree to carry out the exercises as instructed by My Pilates M.O. to ensure safe practice.

Please review My Pilates M.O. Terms of Service before signing the form.

Sign

First Name

Last Name

Date

YYYY