Pilates Health Questionnaire

email address: Leave this field email-address blank:
Homepage: Leave this field homepage blank:
URL: Leave this field url blank:
Comment: Leave this field comment blank:

Health Status Questionnaire

Name*:

Address*:

D.O.B*:

Age:

Home Phone:

Mobile*:

E-mail*:

Emergency Contact Name*:

Emergency Contact Number*:

Doctor's Name*:

Doctor's Number*:

Gender*:

Female Male

Children:

0 1 2 3+

Hours worked per week?:

5-10 10-20 20-40 40-60 60+ N/A

Over 25% of time you spend at work. Do you*:

Sit? Stand? Walk?

How do you sit?:

How do you stand?:

How much do you walk?:

Did anyone in your family die of a heart attack before age 65?*:

Father Mother Brother Sister Grandparent N/A

Have you had any operations?*:

C-Section Hysterectomy Disc removal Hip Replacement Other N/A

If other, please specify:

Do you have pains in your heart and chest?*:

Yes No N/A

Do you often feel faint or have spells of severe dizziness?*:

Yes No N/A

Do you have high/low blood pressure?*:

High Low N/A

Do you have a bone or joint problem such as arthritis, that has been aggravated by, or may be made worse with exercise?*:

Yes No N/A

Is there a good, physical reason, not mentioned here, why you should not follow an activity programme, even if you wanted to?*:

Yes No Other N/A

If other, please specify:

Are you currently, or trying to become, pregnant?*:

Yes No N/A

Have you had a miscarriage?*:

Yes No N/A

Client Lifestyle Profile

Current Occupation:

Is your job stressful?:

Yes Sometimes Not at present Never N/A

What percentage of the day do you spend sitting?:

Do you have repetitive daily movements?:

Yes No N/A

Do you wear high heeled shoes for extended periods?:

Yes No N/A

Do you have any leisure activities? (running, swimming, walking etc.):

Yes No N/A

If yes, please state what those activities are:

What other hobbies do you have? (i.e., reading, gardening, surfing the net):

Client Objectives

What are your goals for this training programme?:

Flexibility Core Stability Posture Strength Other

If other, please specify?:

Do you have a time scale for this goal?:

Short Term Medium Term Long Term Other N/A

If other, please provide rough idea of length of time:

Is it realistic, and are you willing to work at home, alone, with a routine, to attain your goal?:

Yes No N/A

Client Contract

How many hours, weekly, will you commit to working with your trainer?:

How many hours, weekly, will you commit to working at your home routine?:

Do you understand that only consistent adherence to this routine, and quality training time will/may effect change?*:

Client Informed Consent. Please read carefully and sign::

Sign*:

Date*:

Verification:

5 multiply 3 =

Fill in the result

Caroline McGee Mb. 07932 811732 E-mail. caroline@pilates-life.com

POWER POSTURE PERFORMANCE

Mailing List

Pilates Health Questionnaire