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info@pilatesinthe6.com

1-437-291-8500

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Experience positive movement where your mind and body come together

Medical
Questionnaire

*For New Members

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Last Name

Email Address

Date of Birth

Address

Have you been hospitalized in the last 12 months? *

No

Yes

If you answered yes to any question, please elaborate

Are you currently suffering from a medical condition, illness or injury? *

No

Yes

If you answered yes to any question, please elaborate

Gender

Female

Male

Other

Do you have kids?

Yes

No

Have you ever done Pilates before?

Yes

No

If so, how many years?

If yes what are their ages?

What is your reason for wanting to do Pilates?

What, if any, injuries do you have or have had over the last 10 or more years? (ex: high blood pressure, low blood pressure, heart issues, joint problems, car accidents)

Have you had major surgery in the last 10 years?

Do you suffer from:

Diabetes

Epilepsy

Asthma

None of the above

Have you ever been diagnose with:

Osteoporosis

Osteopenia

None of the above

Are you pregnant?

Yes

No

Have you been pregnant in the last 6 months?

Yes

No

If yes, did you have a vaginal birth or Caesarean?

Are you taking any drugs or medication which may affect your ability to exercise?

Yes

No

If yes, please indicate:

Are you seeing any other health practitioners?

Chiropractor

Phsiotherapist

Osteopath

Massage Therapist

I confirm that Pilates in the 6 may use the contents of this form, and any other information I may later provide, for teaching purposes, and that this information:

Your Signature

Today's Date

Thanks for submitting!

contact US

Thanks for submitting!

Find us

Founder: Leslie W.
info@pilatesinthe6.com
Tel:1-437-291-8500

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