PLEASE FILL IN THE FORM BELOW

ANSWERS ARE STRICTLY CONFIDENTIAL

*INDICATES MUST BE COMPLETED

Name *
Name
e.g. are you standing/sitting/driving/lifting etc
Please describe them in as much detail as you can (include recent or old) or n/a if not applicable
If yes, please state number of weeks pregnant or age of children
Do you suffer from any of the following conditions?
Please tick any boxes that apply
If yes, please let us know your T-Scores and if you are on treatment or not
Please provide their contact details below
Please describe in detail
How would you describe your current fitness levels? *
*You only need to complete next questions if taking part in pilates programme*
FOR PILATES CLIENTS ONLY
If yes, please tell us where and to what level and if Matwork or apparatus
What are your goals with your Pilates program?
Please tick any boxes that apply

If you require any further information, please contact me.