Coleman Pilates & Massage

Health Questionnaire:

Your Details:

Your Name (required)

Address Line 1:

Address Line 2:

Town / City:

Postcode:

DOB:

Your Email (required)

Telephone:

Mobile:

Form:

Medical History:
(Please complete as appropriate)
Back problems
YesNo
High Blood Pressure
YesNo
Neck problems
YesNo
Low Blood Pressure
YesNo
Shoulder problems
YesNo
Glaucoma
YesNo
Knee problems
YesNo
Chronic Fatigue Syndrome
YesNo
Other joint problems
YesNo
Repetitive Strain Injury
YesNo
Osteoporosis
YesNo
Surgery
YesNo
Arthritis
YesNo
Had a course of steroids
YesNo
Diabetes
YesNo
Other medical problems
YesNo
Heart Problems
YesNo
Accidents / Falls
YesNo
Lung Problems
YesNo
Are you pregnant
YesNo
Seizures / Epilepsy
YesNo
Been pregnant in last 6 months
YesNo

Please explain below for any YES answers including dates of any surgery:

Please list any prescribed &/or non-prescribed medication you are taking:

Medical Professional Details:
Please give details of medical professionals you are seeing, include your GP, chiropractor, osteopath, physiotherapist etc.

Medical Professional 1:

Address:

Address:

Town / City:

Postcode:

Tel:

Profession:

May I contact them to discuss your needs?: YesNo

Have you been released to exercise?: YesNo

Medical Professional 2:

Address :

Address:

Town / City:

Postcode:

Tel:

Profession:

May I contact them to discuss your needs?: YesNo

Have you been released to exercise?: YesNo

[ By checking the box I understand Classical Pilates involves physical exercise and I will participate in the activity at my own risk. I also RELEASE the teacher from any and all liability arising out of my participation. ]