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Client Questionnaire

All information will be treated confidentially and only used for the purposes of coaching you in Pilates.

Step 1 of 4 - Your details

25%

Your details
Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Mobile Phone*
Email*
Enter Email Confirm Email
Address*
Street Address City Postcode

Goals
What aspect of your health would you like Pilates to focus on?*
- Core stability
- Strength
- Flexibility
- Relaxation
- Stress management
- Posture
- Other
Choose all that apply to you
If Other, please state:*
Your Lifestyle
Your occupation
Does your occupation involve any repetitive movement/activities/postures?*
- Yes
- No
If yes, please give further detail:*
What sports/hobbies are you involved in?
Have you participated in Pilates before?*
- Yes
- No
If yes, how would you describe your ability?*
- Beginner
- Intermediate
- Advanced
Pilates Functionality
The following answers will help me modify exercises to best suit you so please be confident that the answers you give will enable me to programme effectively for your individual needs.
How flexible do you feel?*
Are you able to get down onto the floor and back up again (with the aid of a chair if needs be)?*
- Yes
- No
Are you able to exercise comfortably on your knees for short periods of time?*
- Yes
- No
Are you able to exercise comfortably in 4 point kneeling (hand under shoulders, knees under hips) for short periods of time?*
- Yes
- No
Are you able to sit cross legged comfortably?*
- Yes
- No

Your Present Health
Have you been referred to Pilates by a health professional?*
- Yes
- No
If so, by whom? Why?*
Are you currently experiencing any of the following conditions:
Lower back pain?*
- Yes
- No
If so, please give details:*
Upper/Mid back pain?*
- Yes
- No
If so, please give details:*
Pelvic pain?*
- Yes
- No
If so, please give details:*
Any other spinal conditions?*
- Yes
- No
If so, please give details:*
Any other orthopaedic conditions?*
- Yes
- No
If so, please give details:*
Heart problems?*
- Yes
- No
If so, please give details:*
High or low blood pressure?*
- Yes
- No
If so, please give details:*
Epilepsy?*
- Yes
- No
If so, please give details:*
Pregnancy
Are you currently pregnant?*
- Yes
- No
If yes, what is your due date?*
DD slash MM slash YYYY
Have you had a baby in the past year?*
- Yes
- No
If yes, when was it born?*
DD slash MM slash YYYY
Was the delivery:*
- Normal
- Caesarean
Past Illnesses, Injuries and Surgery
Have you had any recent injuries or surgery?*
- Yes
- No
If yes, please state:*
Injury / Surgery Date

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Have you been diagnosed with or had treatment with any of these conditions:*
- Asthma
- Osteoarthritis
- Stroke
- Diabetes
- Depression
- Bronchitis
- Cancer
- Dermatitis
- COPD
- Osteoporosis
- None of the above
If you have experienced any of the above, please give details:*
Have you ever had any other major illnesses not included above?*
- Yes
- No
If so, please give details:*
Neck Problems:
Do you have any neck pain/problems?*
- Yes
- No
If so, please give details:*
Do you get headaches frequently?*
- Yes
- No
If so, please give details:*
Do you lose your balance because of dizziness?*
- Yes
- No
If so, please give details:*
Do you suffer from pins and needles, numbness or weakness in your muscles at all?*
- Yes
- No
If so, please give details:*
Shoulder Problems:
Do you have any problems with your shoulders?*
- Yes
- No
If so, please give details:*
Medication:
Are you currently taking any medication?*
- Yes
- No
If yes, please state:*

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Have you ever taken anticoagulants (drugs to thin the blood)?*
- Yes
- No
Please list any other health issues that you suffer with (not already mentioned) that may affect your ability to exercise.

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Consent
Pilates Consent:*
I consent and agree to the following statement
The Pilates programme I will participate in will begin at a low level and will offer more advanced options depending on my fitness level and spinal condition. I acknowledge that it is important that I exercise at my own rate and within my own level of comfort and ability. If at any time I am unsure of the exercise or experiencing any pain or discomfort, I will stop the exercise and inform the instructor.

Even though Pilates is a low risk and low impact form of exercise, there still is a risk of danger. These include abnormal blood pressure, fainting, abnormal heart rhythm and in rare cases, heart attack, stroke or death. Whilst every care is taken it is impossible to predict the body’s exact response to exercise. I acknowledge that every effort will be made to minimise these risks. It is advisable to inform your GP prior to starting any new form of exercise.

Please advise the instructor before commencing any session that if, for any reason your health or ability to exercise changes. These sessions are not a substitute for medical advice or treatment. If you have any doubts about the suitability of Pilates you should refer back to your medical practitioner. The instructor can accept no liability for personal injury related in a session if:
- Your doctor has, on health grounds, advised against practising Pilates
- You fail to observe instructions on safety and technique
- Such injury is caused by the negligence of another participant or obstruction (in your own home if undertaking an online Pilates session)
GDPR*
I consent and agree to the following statement
Your medical information will only be viewed by myself for the purposes of informing the programming our Pilates sessions together. It will not be shared with any other individual or organisations and will be destroyed when it is no longer useful (i.e. when you stop doing Pilates with me). Your information will be kept safely at my home and if you submit it electronically, it will be stored in a password protected folder.
Phone
This field is for validation purposes and should be left unchanged.

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