New Client Health Questionnaire

Name

First

Last

Email

What is your Occupation?

Does your occupation involve any repetitive movements / activities or postures such as: predominantly sitting / desk based / lifting / bending or similar. If so please explain.

What sports or hobbies are you involved in?

Have you had to discontinue or modify your sports or hobbies for any health reason?

Yes
No

If YES please provide details:

Have you ever practiced Pilates, Fascial Movement or Barre before?

Yes
No

If YES, what style (e.g. Body Control, STOTT) and for how long?

Have you been referred by a specialist health practitioner?

Yes
No

If YES, by whom?

This could be your Physiotherapist or Surgeon for example.

What aspect of your health would you like to concentrate on?

Please add anything additional below:

Are you currently experiencing any of the following conditions?

Please tick any boxes that apply.

Please add any additional medical conditions or further details below:

Are you pregnant?

Yes
No

If YES, how many weeks pregnant are you?

Have you had any complications in your pregnancy? If YES... Please share details:

Have you ever had an episode of low back pain?

Yes
No

If YES, how many previous episodes of low back pain have you had?

Have you had any recent injuries or surgery?

Yes
No

If YES please share details:

Do you have any pain or restricted movements in any joints e.g. hip, shoulder or knee?

Yes
No

If YES, please give details:

Do you suffer from any bone or joint problems?

Yes
No

If YES, please give details:

Have you ever been diagnosed with Hyper-mobility?

Yes
No

If YES, please give details:

Do you get headaches frequently?

Yes
No

If YES, please give details:

Do you lose your balance because of dizziness?

Yes
No

If YES, please give details:

Do you suffer from pins & needles at all?

Yes
No

If YES, please give details:

Are you currently taking regular medication?

Yes
No

If YES, please list:

Have you ever taken steroids?

Yes
No

If YES, please give details:

Have you ever taken anticoagulants (drugs to thin the blood)?

Yes
No

If YES, please give details:

Please list any health problems that you suffer with, not already mentioned, that may affect your ability to exercise:

Please expand on any of the questions above and give any further relevant details.

How would you like to feel after 3 months of training with me?

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.

I understand

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

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 understand

Name

First

Last

I confirm that the information provided in this Health Form and my PAR-Q form is correct.

Contact us

07534 099 624

hello@greenroomhealth.co.uk

New Client Health Questionnaire