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Full Name*

Date of Birth*

Address

Post Code

Phone

Email*

Emergency Contact & Contact no.

Have you done Pilates before?

What is your occupation?

What other hobbies or sports are you involved with?

Does your occupation involve any repetitive movements or prolonged postures?

Are you currently experiencing any of the following conditions?

Lower Back Pain

Pelvic Pain

Any other spinal consition

Any other orthopedic condition

Heart Problems

High or low blood pressure

Epilepsy (Grand mal seizures)

If you have checked any of the conditions above please give further details:

Are you pregnant?

Have you had any recent injuries or surgery?

Have you been diagnosed with or have had treatment for any of the following conditions

Asthma

Arthiritis

Stroke

Diabetes

Bronchitis

Cancer

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