Health Questionnaire — My Pilates M.O — 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

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

Please give details

Have you had surgery in the past year?

Yes

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?

Have you suffered from any pregnancy related conditions such as Gestational Diabetes or Pelvic Girdle Pain?

Yes

Please provide details

POSTNATAL QUESTIONS (Please complete if applicable)

When was your last baby delivered?

Please briefly describe your labour and delivery I.e induced, vaginal delivery, emergency c section, episiotomy etc.

Are you breastfeeding?

Yes

Have you been cleared to exercise by your Midwife/HV or GP?

Please give the date of your conversation/meeting:

Have you been physically examined by a medical professional for Diastasis Recti (separation of the abdominal wall) ?

Please give details if applicable:

If a caesarean section was performed, has your scar been physically examined by a medical professional?

Yes

N/A

If an episiotomy was performed, has your scar been physically examined by a medical professional?

Yes

N/A

Have you been advised about Pelvic floor exercises and shown how to do them?

Yes

Have you been advised to avoid any activities by a healthcare professional?

Please give details if applicable:

Have you been referred to a healthcare professional since your delivery? E.g. Womens health physio.

Please give details if applicable:

Do you have any concerns about your physical or mental health?

Please give details if applicable:

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 and Pregnancy Terms before signing the form.

Sign

First Name

Last Name

Date

YYYY

Pregnancy Health Questionnaire

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