Author: David Osborne
Last saved by: Emily Osborne

Pilates / Yoga Assessment Questionnaire

Contact details

First Name: |
Family Name: |
Date of Birth: |
Contact Telephone Number: |
Email: |
Emergency contact name: |
Emergency contact number: |

YOUR INFORMATION WILL BE TREATED CONFIDENTIALLY. 

Your medical history
Do you suffer or have you suffered from any of the following?
If yes to any, please provide brief details: 
| Please circle / tick

1.

a) High or low blood pressure?

b) Any Medication?

Yes 

Yes

No

No

2. | Heart problems? | Yes | No

3.

Epilepsy?
If yes, have your seizures been stabilised via medication?

Yes

No

4. | Asthma or breathing problems? | Yes | No
5. | Have you been diagnosed with osteoporosis? | Yes | No

6.

Have you had any admissions to hospital or surgery in the last 5 years?
If yes, please specify:

Yes

No

7. | Are there any physical issues (including problems with the neck, back, hips, knees, ankles, feet etc) and / or mental health conditions (including anxiety, depression and stress) that your instructor should be aware of or that you would like them to be aware of in treating you as a Pilates / Yoga client? | Yes | No

If you have answered yes to question 7 above please provide further information (including whether you are currently experiencing the problem, things that help, things that make the pain / problem worse or trigger it, any medications):

Please Note: If your health changes so that you subsequently answer yes to any of the above questions please inform your instructor. 

What are your goals in relation to Pilates / Yoga classes?

I have read, understood and completed this questionnaire and all questions have been answered to the best of my knowledge:

Signed:						Date: 

I consent to this form and the information on it being filed securely whilst I am a Pilates / Yoga client and to being contacted regarding Pilates / Yoga information by the instructor:

Signed:						Date :

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Emily Osborne