New Client Health Questionnaire

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Does your occupation involve any repetitive movements / activities or postures such as: predominantly sitting / desk based / lifting / bending or similar. If so please explain.
Have you had to discontinue or modify your sports or hobbies for any health reason?
Have you ever practiced Pilates, Fascial Movement or Barre before?
Have you been referred by a specialist health practitioner?
This could be your Physiotherapist or Surgeon for example.
What aspect of your health would you like to concentrate on?
Are you currently experiencing any of the following conditions?
Please tick any boxes that apply.
Are you pregnant?
Have you ever had an episode of low back pain?
Have you had any recent injuries or surgery?
Do you have any pain or restricted movements in any joints e.g. hip, shoulder or knee?
Do you suffer from any bone or joint problems?
Have you ever been diagnosed with Hyper-mobility?
Do you get headaches frequently?
Do you lose your balance because of dizziness?
Do you suffer from pins & needles at all?
Are you currently taking regular medication?
Have you ever taken steroids?
Have you ever taken anticoagulants (drugs to thin the blood)?
Please expand on any of the questions above and give any further relevant details.
You may wish to feel stronger, more flexible, calmer, happier in your own skin.... By setting your intention we can both ensure you stay focussed on your goals. Joseph Pilates famously said after 1 month you will feel the difference, after 2 months you will see the difference and after 3 months you will have a whole new body.
Your program whether Pilates/Barre/Fascial Movement will begin at a low level and will be advanced in stages depending on your fitness level. We may stop the exercise session because of signs of fatigue or excessive strain. It is important for you to realise that you may stop when you wish because of feelings of fatigue or any other discomfort.
There exists the possibility of certain dangers when exercising. They include abnormal blood pressure, fainting, irregular, fast or slow heart rhythm and in rare circumstances heart attack, stroke or death. Whilst every care will be taken, it is impossible to predict the body’s exact response to exercise. Every effort will be made to minimise these risks by evaluation of preliminary information relating to your health and fitness and by observations during exercising.
I understand any personal programme will be specifically designed to take into account the details given in my health questionnaire. Therefore, any programme of exercises should only be undertaken when in a Pilates/Barre/Fascial Movement session, class or when I have been given specific instructions to exercise on my own. Modification options will be given during group classes where applicable.
I confirm that the information provided in this Health Form and my PAR-Q form is correct.