Health Screening Form for Group Pilates Class
Please fill out the following information to ensure your safety during the class.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any existing medical conditions?
Diabetes
Heart Condition
Asthma
Back Pain
None
Other
If yes, please specify:
Have you had any surgeries in the past 5 years?
Yes
No
If yes, please provide details:
What are your goals?
Increase fitness
Rehabilitation
More balance & flexibility
Social connection
Move without aches/pains
Other
Signature
Continue
Continue
Should be Empty: