Back Harmony Pilates – Pre-Screening Quiz
Please answer these quick questions before booking your Pilates class.This helps us make sure you join the safest session for your needs.This form is not medical advice — if in doubt, always consult your GP or physiotherapist.
Section 1: Basic Details
Name
*
First Name
Last Name
Email
*
example@example.com
Section 2: Quick Screening Questions
How would you describe your back pain right now?
*
Mild / manageable
Moderate / sometimes difficult
Severe / stops me from daily activities
Can you comfortably get up and down from the floor?
*
Yes
No
Not sure
Have you had any recent accidents, injuries, or falls?
*
Yes
No
Do you have any diagnosed health conditions your instructor should be aware of?
*
Section 3 – Goals & Consent
What’s your main goal?
*
Reduce pain
Improve posture
Build strength
Build strength
Other
Disclaimer & Consent
*
I confirm I have answered truthfully and understand that this class is general exercise, not medical treatment. If I develop new or worsening symptoms, I will stop and seek medical advice.
Submit
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