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 any health conditions below that apply to you, then give details in the 'more details' box. If none are applicable tick 'None of the above'. (required) High Blood Pressure (medication, list below)

Low Blood Pressure

Arthritis

Diabetes (T1 or T2? Detail below)

Epilepsy

Anxiety/Depression/Mental Health

Heart Problems/Chest Pain

Asthma

Detached Retina or Eye Problems

Back/Knee/Neck/Joint Problems (give details below)

Recent Brakes/Sprains/Fractures/Operations (give details below)

Are you Pregnant or recently given birth? (give details of trimester or when)

Fainting or fits?

Any other conditions which affect mobility or likely to cause concern in Pilates/Yoga classes? (give details below)

None of the above

Please give MORE DETAILS here, or list any other conditions:

Signed (PRINT FULL NAME)(required)

Date(required)