Health Questionnaire

First Name(required)

Surname(required)

Email(required)

Telephone Number(required)

How Did you hear about classes with Rebecca?(required)

Which classes are you joining? (Please choose one)(required)

Have you attended a Pilates/Yoga class before? (Please choose one)(required)

If yes, how long ago and for how long did you practice?

Are you happy to be adjusted by the teacher in your Pilates / Yoga class? (Please choose one)(required)

Please TICK if any of the following health conditions apply to you. If these are not applicable please tick 'None of the above'. (required) High/Low Blood Pressure

Fainting/Fits

Arthritis

Diabetes

Epilepsy

Anxiety/Depression/Mental Health

Heart Problems/Chest Pain

Asthma

Detached Retina or Eye Problems

Back/Knee/Neck/Joint Problems

Recent Brakes/Sprains/Fractures/Operations (list all)

Are you Pregnant or recently given birth?

Any other conditions which affect mobility or likely to cause concern in Pilates/Yoga classes?

None of the above

Other/More Details:

Signed (PRINT FULL NAME)(required)

Date(required)