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Confidential Health Questionnaire

Please fill out the below ahead of doing a Group Class or Private Session for the first time

First Name

Email address

Last Name

Date of Birth

Do you have or have you experienced any of the following conditions?

Heart Disease or High/Low Blood Pressure

Asthma

Neck Pain or Back Pain

Spinal Disorders

Numbess/Tingling

Swelling in Joints

Arthritis

Seizures

Kidney Disease

Diabetes

Hepatitis

Hernia

Cancer/Tumors

Ulcers

Varicose Veins

Tuberculosis

Abdominal or Bowel Disorders

Skin Disorder or Rashes

None of the above

Are you currently suffering from a medical condition, illness, or injury or are you be pregnant?

No

Yes

If you answered yes to any question, please elaborate in detail below. Do also list any medications you might be taking.

Initials

Today's Date

I hereby confirm that the information above is correct and that to my knowledge I have not withheld any information which may adversely affect me. I declare that exercises prescribed or administered to me are undertaken at my own risk. I will not hold the teacher responsible for injuries arising there from. I agree to the above terms and conditions.

Thank you!

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e; amy@acbpilates.co.uk m: 07956 337231

London, UK