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Health Questionnaire

Name:

 

Address:




Postcode:

Phone Nos:

Email:

Occupation:

Age/DOB:

How did you find The Pilates Studio Kent?
If not listed please state how here

Medical Questionnaire

 

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

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

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

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

5. Do you have weak pelvic floor muscles?

6. Do you smoke?

7. Are you dieting or fasting?

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

Gout

Glandular Fever

 

 

Stroke

Rheumatic Fever

 

 

Diabetes

Dizziness or fainting

 

 

Epilepsy

Stomach or Duodenal Ulcer

 

 

Hernia

Liver or Kidney problems

 

 

Special training considerations body overview

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

Arthritis

Neck

Back

Asthma

Knees

Ankles

Cramps

Shoulders

Muscular Pain

Other

 

 

 

 

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

       

Tel 01622 763965

   

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