Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you do physical activity? *

Yes

No

In the past month, have you had chest pain when you were not doing physical activity? *

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

Is your doctor currently prescribing medication for your blood pressure or heart condition? *

Yes

No

Are you currently pregnant, or have you recently given birth? *

Yes

No

Have you had any recent surgeries, injuries, or musculoskeletal issues (e.g. back pain, sciatica, shoulder/hip/knee problems)? *

Yes

No

Do you experience any chronic pain or conditions (e.g. arthritis, fibromyalgia)? *

Yes

No

Do you have asthma, diabetes, or any other long-term medical condition we should be aware of? *

Yes

No

Are you currently taking any medications that may affect your ability to exercise safely? *

Yes

No

I confirm that the information I’ve given is accurate to the best of my knowledge. *

Yes

I understand that I take part in Pilates sessions at my own risk and have consulted a medical professional if necessary. *

Yes