Language
English (UK)
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Health Questionnaire
Answer a few questions to help tailor your reformer studio session.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: 00000-000000.
Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: 00000-000000.
Do you have any current or past injuries, medical conditions, or surgeries we should be aware of?
*
PAR-Q
*
Rows
Yes
No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel fain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Are you currently taking any medications?
What is your experience level with Pilates or Reformer classes?
*
Please Select
Beginner
Intermediate
Advanced
Other
Do you have any specific goals or concerns for your sessions?
Do you agree to inform your instructor of any changes to your health or physical condition?
*
Yes
No
Signature (to confirm the information provided is accurate)
*
Submit
Submit
Should be Empty: