Initial consultation form - functional pilates

First Name*

Last Name*

E-mail*

Mobile Number*

Address*

What are you hoping to gain from your appointment?

Please give me a brief description*

Activity / Occupation

What is/was your main occupation?*

What exercise do you take part in?*

Previous Medical History

1. Have you had any serious illnesses or accidents, including car accidents?

YES
NO

If you answered YES to Q1 above, please give brief details.

2. Have you broken any bones?

YES
NO

If you answered YES to Q2 above, please give brief details.

3. Have you ever been hospitalised? (Including issues during childbirth)

YES
NO

If you answered YES to Q3 above, please give brief details.

4. Have you ever had any repetitive illnesses? (e.g. Chronic Fatigue, ME, Glandular Fever)

YES
NO

If you answered YES to Q4 above, please give brief details.

Please list any medications that you may be taken

General Information

1. Do you have any allergies?

YES
NO

If you answered YES to Q1 above, please give brief details.

2. How are your energy levels?

GOOD
POOR

3. How well do you sleep?

WELL
BADLY

4. Do you have a healthy diet?

YES
NO

Your visit today

1. What is the main reason for your visit with me?*

2. Do you have any other joint or movement limitations?

YES
NO

If you answered YES to Q2 above, please give brief details.

3. Are you currently experiencing any pins & needles?

YES
NO

If you answered YES to Q3 above, please give brief details.

4. Are there situations that aggravate your condition?

YES
NO

If you answered YES to Q4 above, please give brief details.

5. Are there situations that relieve your condition?

YES
NO

If you answered YES to Q5 above, please give brief details.

6. On a scale of 1 -1 0 (10 being the most uncomfortable), what number would you give your condition at this time?*

7. Where is the site of your condition?*

If you answered YES to Q7 above, please give brief details.

Please sign (typed version is fine)*

Please date*

Please date