Name

Phone

Email Address

Date of Birth

Address

Occupation

How did you hear about Pilates Nelson?

Main reason for attending Pilates?

What regular physical activity do you do?

Do you have any of the following conditions? Do you have any of the following conditions? Diabetes Asthma High Blood Pressure Low Blood Pressure Heart Problems

Are you on Medication? Are you on Medication? Yes No

Do you have joint problems, arthritis or osteoporosis? Do you have joint problems, arthritis or osteoporosis? Yes No

Do you have back pain? Do you have back pain? Yes No

If yes, how and when did it happen?

Are you pregnant or have been pregnant in the last 3 months? Are you pregnant or have been pregnant in the last 3 months? Yes No

Do you have pelvic prolapse? Do you have pelvic prolapse? Yes No

Have you ever had any major injuries or surgery? Have you ever had any major injuries or surgery? Yes No

If yes, when and why did it happen?

Is there any physical reason you should not exercise?

Declaration Declaration I certify my answers are true and complete. I assume responsibility for any changes in medical condition that may affect my ability to exercise. I understand payment is due prior to class. I have read and accept the Privacy Policy and Cancellation Policy. I agree to recieve Pilates Nelson's newsletter and updates about the service via email or txt message.