Health Questionnaire

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender *

Female

Non-binary/non-conforming

Male

Prefer not to say

Date of birth *

MM

DD

YYYY

1. Does your work/ sport involve any of the following?

Tick all that apply

Sitting for long periods

Lifting heavy weights

Bending

Driving

Standing

Any other repetitive action

Emergency Contact Phone Number *

(###)

###

####

Have you experienced any of the following, past or present?

Tick all that apply

Heart Disease or Defect

Shortness of Breath

Chest Pain

Diabetes

High Blood Pressure

Low Blood Pressure / Fainting

Asthma

Arthritus or Osteoporosis/ Osteopenia

Major Surgery in the last 10 years

Minor Surgery in the last 2 years

Epilepsy or Seizures

Back problems or pain

Neck problems or pain

Restrictive Movement or pain in any other joints (eg. Hip, Knee, Ankle, Shoulder)

Hypermobility

Panic Attacks

Recent Pregnancies

Currently Pregnant

Headaches

Confirm information is correct* *

I have read, understood and completed this questionnaire to the best of my knowledge, and I have read and understood the terms and conditions

Confirm your responsibility* *

I take full responsibility for my health during Pilates classes and will inform my instructor of any medical changes that may affect my ability to participate. I agree to assume full responsibility for any injuries which I might incur as a result of participating in this virtual class. I will monitor my own safety and fitness level.