PILATES SCREENING FORM


NAME:

DATE:

ADDRESS:

HOME TEL:

MOBILE:

EMAIL:


Do you have any injuries, aches or pains ? have you had any surgery ?



Are you pregnant ? have you recently given birth ?
normal delivery or c-section ?



Are there any other health concerns ?
e.g. Asthma, Diabetes, High Blood Pressure, Medications ?



Are you currently doing other kinds of therapy ?
e.g. Massage, Physiotherapy, Osteopath, Chiropractic, etc ?



Are you active in any sports, exercise programmes, physical activity ?




Have you had any past training in Pilates? in which method & to what level ?



What is your occupation ? what does your typical day involve physically ?



What are your goals ? what do you want to gain most from these classes ?



NB: information supplied will be treated confidentially
Please Return To: Wendy Bernardelle, 104 Fallow Court Avenue N12 0BG