Pilates Class Questionnaire
Please complete this form honestly to help us provide a safe and effective Pilates session.
Participant name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
What does a typical day look like for you?
*
Mostly seated – I spend most of the day sitting, e.g. desk-based work or studying.
Seated with some movement – I sit for much of the day but regularly get up, walk around, or run errands etc.
On my feet quite a bit – My work or daily routine involves a fair amount of standing and walking.
Very active day-to-day – I’m on my feet for most of the day and/or have a physically active job or lifestyle.
Retired / not currently working, but active – I regularly walk, exercise, socialise, garden, or keep busy during the day.
Retired / not currently working, with a quieter routine – I spend more of the day seated or doing lighter activities.
Are you currently taking any medication that could affect you during the session?
*
Yes
No
If yes, please provide details of the medication.
Do you have any illnesses or disabilities?
*
Yes
No
If yes, please provide details.
Have you ever been diagnosed with any of the following conditions?
Asthma
Metal Implant
Heart Condition
Diabetes
Pacemaker
Rheumatoid Arthritis
Epilepsy/Seizures
High Blood Pressure
Low Blood Pressure
Blood Disorder
Other
Do you have any injuries or joint issues?
*
Yes
No
If yes, please provide details.
Have you had surgery in the past 12 months?
*
Yes
No
If yes, please provide details.
Have you been referred by a health professional? If so, what reason?
*
Are you or have you been pregnant in the past 12 months?
*
Yes
No
If yes, how many weeks pregnant are/were you?
Is there any reason you should not participate in physical activity without medical supervision?
*
Yes
No
Please list any other fitness classes, exercise programmes or sports clubs you attend regularly (ie crossfit, football, yoga) and frequency.
If yes, please provide details.
I acknowledge that the information provided is accurate and I understand the risks associated with participating in physical activity. Do you confirm?
*
Yes, I confirm
Submit
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