Title Mr Miss Mrs Name * First Name Last Name Date of Birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Telephone Number * Emergency Contact * First Name Last Name Emergency Contact Telephone Number * Medical Questions * Do you currently, or have you ever suffered from any of the following? Heart trouble Epilepsy High/Low blood Pressure - please indicate which Diabetes Arthritis Asthma/Breathing trouble Dizziness or feeling faint Headaches/Migraines Neck/Shoulder Pain Blackouts Back/spinal Pain Recent surgery Prescribed Medication Had a baby within the last 6 months Varicose veins Sciatica No known health conditions Further Information/Medication If you selected any of the above, please provide further information here. Is there any other reason that you believe may prevent you from taking part in any regular physical activity? * Where did you hear about B Pilates? What are your goals you want to achieve from attending Pilates classes? Declaration * I have answered all question in this form honestly and I am aware that if I have answered yes to any of the above questions, I have sought medical approval prior to class. I agree to inform my instructor on any changes to my health or fitness. I understand that should I give less than 24 hours’ notice for cancellation of a 1-2-1 or PAYG space, 50% of the payment will still be chargeable. Date MM DD YYYY Thank you for your health and safety questionnaire! I will be in touch shortly.
