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Health declaration

Please fill out the following form.

First name*

Last name*

Date of birth

Day

Month

Year

Phone

Address

Emergency Name and Number*

Do you have or have you suffered from any of the following conditions?*

Diabetes

Heart Trouble

Low Blood Pressure

High Blood Pressure

Asthma

Epilepsy

Osteoporosis

Arthritis

Joint Replacement

Neck Pain

Back Pain

Headaches/ Migraines

Smoker

Numbness/Tingling

Cancer

Pinched Nerve

Bone/Stress Fracture

Hypermobile Joints

Major Accident

Discogenic Back Pain

Anxiety

Depression

Shoulder/Elbow/Wrist Problems

Hip/Knee Problems

Ankle/Foot Problems

Long Standing Medical Conditions (ie MS/Parkinson Disease)

Nill

If you have ticked yes to any of the above, please provide further information.

Is there any other information or conditions not listed above that your Pilates Instructor should be aware of?

Please advise us of any medications or medical treatment you are currently taking?

Are you currently pregnant?*

Yes

If you had a previous pregnancy, have you had any issues post pregnancy?

What is you main goals to achieve by undertaking Pilates?*

Signature*

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