At Studio Pilates we like to give you the toughest workout possible, while keeping you safe at all times. It is very important that our instructors are aware of any health issues, current or previous injuries, and any aches or pains that may affect your workout, no matter how minor. Please outline the relevant information below and provide as much detail as you can before starting your Studio Pilates classes.

Your information will be securely kept in the strictest confidence and shared only with the instructors that are required to know this information to be able to help you.

This medical form in compulsory for all new members of Studio Pilates and this form must be filled in before attending your orientation workout.

   

Choose Your Studio Location: 
First Name:  *
Surname:  *
Email:  *
Phone:  *
Do you have any health or medical problems? Eg; Heart Issues, asthma, high blood pressure: No
Yes
Details: 
List any existing injuries or physical pain that you have & when it occurred.: 
Do you currently experience any pain in your body that effects any movements on a day to day basis?: 
Are you currently pregnant or have you recently given birth in the last 6 months?: No
Yes
If you are pregnant, please list how many weeks.: 
If you have given birth, please list how long ago and type of birth.: 
Have you had any recent surgeries?: No
Yes
Please list details of your surgery: 
Can you lie on your stomach without experiencing any pain or discomfort?: No
Yes
Can you lie on your side without experiencing any pain or discomfort?: No
Yes
Can you lie on your back with your feet in the air without experiencing any pain or discomfort?: No
Yes
Can you sit on a chair without experiencing any pain or discomfort?: No
Yes
Can you raise your arms up to shoulder height without experiencing any pain or discomfort?: No
Yes
Do you experience any pain or discomfort in your body while sleeping?: No
Yes
Do you experience any pain or discomfort in your body when picking something up off the floor?: Yes
No
Do you experience any pain or discomfort in your body when getting out of the car?: No
Yes
Do you experience any pain or discomfort in your body when doing a squat at the gym?: Yes
No
Do you experience any pain or discomfort in your body while standing?: Yes
No
Please provide any further information that you can so that we can pass the details on to your instructor: 
All the information given is true and correct and I have provided Studio Pilates with all the information about my health and wellness that may restrict my ability to perform a class:  * Yes
I agree that my body is my responsibility and I will let my instructor know if I experience any pain or discomfort during the class.:  * Yes
I acknowledge that if the instructor feels that I am unfit to participate in the workout, they will request I discontinue the workout.:  * Yes