Initial consultation form

First Name*

Last Name*

E-mail*

Mobile Number*

Address*

What are you hoping to gain from taking pilates classes? - 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

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?*

Declaration

I have read, understood and completed this form.
I confirm I am voluntarily engaging in an acceptable level of exercise, and my participation may involve a risk of injury.

Any questions I had were answered to my full satisfaction. I will inform the instructor of any new or unusual symptoms; changes in my medication; results of any investigations or treatment.

NOTE:

Please ensure that you have read and understand the relevant Booking Policy for the class that you are attending, as you are required to agree to these terms when attending a class.

I can confirm that I have read the relevant class booking policy and agree to the terms.

Signature (please type your name)*

Date*

Date

Initial consultation form

Activity / Occupation

Previous Medical History

General Information

Your visit today

Declaration