Personal Details

Please complete this form and the Health Questionnaire to help Anya Pilates understand more about you and your goals.
PERSONAL DETAILS
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Phone*

Area CodePhone Number
Email*
example@example.com
D.0.B*

MonthDayYear
Emergency Contact 1*
Emergency Contact 2*
LIFESTYLE
What brought you to Pilates?*
Occupation*
Hrs Per Week*
Is more that 25% of your time spent on any of the following? (please tick)*

Sitting at a deskLifting/carrying loadsWalkingDrivingSport/trainingStandingNone of the above
Do you consider your work to be (please tick)*

StressfulActiveSedentaryNone of the above
Are you exercising at present?*

YesNo
If yes, what are you doing?
Exercise currently undertaken
AIMS AND GOALS - What aspects of your health and fitness would you like to concentrate on? (tick as many as appropriate)*

StrengthFlexibilityToningStress reductionPostureRelaxationWeight lossCore strengthOther
Should be Empty: