Personal Details

HEALTH QUESTIONNAIRE

In the interests of your own safety and well being, please complete the questions below. If you are aged between 15 and 69, the questionnaire will tell you if you should check with your doctor before you start. If you are over 69 years of age and you are not used to being very active, please check with your doctor.

Anya Pilates Glasgow will treat all information with the utmost confidentiality

Do you ever feel pain in your chest when you do physical activity?*

YesNo

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

YesNo

Have you ever had chest pain when you are not doing physical activity?*

YesNo

Do you ever feel faint or have spells of dizziness?*

YesNo

Do you ever have a joint problem that could be made worse by exercise?*

YesNo

Have you ever been told that you have high blood pressure?*

YesNo

Have you ever been told that you have high blood pressure?*

YesNo

Are you currently taking any medication of which we should be made aware?*

YesNo

If so, what is the medication?

Medication we should be aware of

Are you pregnant or have you had a baby in the last six months?*

YesNo

Is there any reason you should not participate in physical activity?*

YesNo

If so, why?

Reason for not participating in physical activity

Do you, or have you ever, any of the following? (please tick):

If there is anything else we believe we should know about, please describe here:

IF YOU HAVE ANSWERED 'YES' TO ONE OR MORE QUESTIONS please talk to your doctor before you start becoming more physically active. Tell your doctor about the questionnaire and which question(s) you have answered YES. Talk with your about the Pilates classes you wish to participate in and follow his/her advice. If necessary, your doctor may contact Anya Pilates Glasgow.

IF YOU HAVE ANSWERED 'NO' TO ALL QUESTIONS you can be reasonably sure that you can start to become more physically active and take part in Pilates classes. Remember to start slowly and build up gradually.

PLEASE NOTE If your health changes so you subsequently answer 'YES' to any of the above questions, please inform Anya Pilates Glasgow immediately. If you feel unwell due to temporary illness such as cold or flu delay becoming more active.

I HAVE READ, UNDERSTOOD AND COMPLETED THIS HEALTH QUESTIONNAIRE. I will participate in the Pilatesexcercises at my own risk and I confirm that if I suspect any adverse affect brought on by my participation I will immediately report such to Anya Pilates Glasgow.

Name*

First NameLast Name

Date*

Date