New Client Registration & Health Screening Form

New Client Registration & Health Screening Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Exercise pre-screening form

This screening tool is designed to identify people who will need medical clearance before exercising with a movement professional. No warranty of safety should result from its use. The screening tool in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Pleasant Pilates for any loss, damage, or injury that may arise from any person acting on any statement or information contained in this tool.

Rows	YES	NO
1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
6. Do you have any other serious health conditions that may require special consideration for you to exercise?

Exercise pre-screening form