Health Quetionnaire

Name:

Email:

Phone:

Next of Kin/Emergency Contact:

Please read the following questions and answer each one honestly

Click the boxes below

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

No

Do you feel pain in your chest when you do physical activity?

Yes

No

In the past month, have you had chest pain while you were not doing physical activity?

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes

No

Do you have a bone or joint problem that could be made worse by physical activity?

Yes

No

Is your doctor currently prescribing drugs for your blood pressure or heart condition or are you taking any other medication?

Yes

No

Are you pregnant or recently had a baby?

Yes

No

Have you had any recent injuries or operations?

Yes

No

If yes, please give details.

Do you know of any other reason why you should not do physical activity?

Yes

No

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If you answered YES to one or more questions

Please contact Juliet as you may need to talk to your health professional BEFORE you start attending Pilates sessions.

If you have previously practiced Pilates, please indicate for how long and your level.

How did you hear about the class?

I have read, understood and completed the questionnaire. Any questions I had were answered to my full satisfaction and I take responsibility for my health in class.

I have read and understood the Juliets Privacy Policy at the time of completing this form and consent to my data being used for the purpose of delivering Pilates classes, workshops and retreats.

I am happy to receive e-mails regarding classes, timetable amendments, workshops, retreats or any other information relevant to Pilates with Juliet.

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Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the above questions. Therefore please notify Juliet if there are any changes to your health within this time period.

Pilates Classes with Juliet

Health Questionnaire

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Health Questionnaire

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Contact

Phone: +44 (0) 773 6359062

juliet@julietspilates.com