Occupation:

Age/DOB:

How did you find The Pilates Studio Kent?
Please select I am an existing customer From a friend Email From the internet From a leaflet Not listed If not listed please state how here

Medical Questionnaire

1. Anyone in your family with heart disease, high blood pressure, stroke, raised cholesterol levels?

Yes No

2. Are you a male over 35 or female over 45 and not used to regular exercise?

Yes No

3. Are you on any prescribed medication (eg HRT)?

Yes No

4. Have you given birth within the last 6 weeks?

Yes No

5. Do you have weak pelvic floor muscles?

Yes No

6. Do you smoke?

Yes No

7. Are you dieting or fasting?

Yes No

Do you have or have you had? please tick all that apply

Gout

Stroke

Diabetes

Epilepsy

Hernia

Special training considerations body overview

Have you ever had or do you have Any pain or major injuries particularly the following areas?

Arthritis

Asthma

Cramps

Other

If you answered positively to any of the above - please can you give me as much information as possible below: