The Complete Core Studio

Name:

Date of Birth:

Address:

Email:

Phone:

Emergency Contact & Phone Number:

Medical History

Have you ever had a heart condition or suffered from a stroke?

Do you ever experience unexplained pain in your chest at rest or during physical activity/ exercise?

Do you ever feel faint or dizzy during physical activity/ exercise which can cause you to lose balance?

Have you had an asthma attack requiring immediate medical attention in the last 12 months?

If you have diabetes (1 & 2), have you had difficulty controlling your blood glucose in the last 3 months?

Have you had surgery in the last 6 months?

Do you have any other medical conditions that may prevent you from participating in physical activities?

Details:

Are you pregnant or have given birth in the last 6 weeks:

If you have previously given birth, please give dates or details (natural, caesarean, any complications, abdominal separation)

Have you had or do you have any pain or major injuries in the following areas?

Neck

Shoulder

Back

Hips

Knee

Ankles

Please add details to any of the above pain or major injuries:

How would you rate the pain that you had during the past week?

	1	2	3	4	5	6	7	8	9	10
No Pain											Pain as bad as it could be

Do you have or have you ever had:

Osteoporosis

Arthritis

Rheumatic Conditions

Gout

Asthma

Epilepsy

Hernia

Vertigo

Cancer

High Blood Pressue

Reflux

Covid- long covid

Can you think of any other reason that we would need to modify your Pilates program?

Current Exercise Regime

Do you currently Exercise?

Are there any positions or movements which you find uncomfortable?

Have you performed pilates before? Please give details?

How hard would you like to work in your pilates class?

Light

Moderate

Vigorous

Goals

Improve core stability

Enhance flexibility

Improve muscular strength

Improve posture

Tone the body

Lose weight

Relaxation

Stress Management

Injury Management

Physical Touch and Correction

I will monitor and correct your Pilates technique in a variety of ways including through verbal cues and physical touch to move your body into the correct position or check that the correct muscles are working. Do you consent to having me touch you to perform these corrections?

Lifestyle

What is your occupation?

Does your occupation involve repetitive movements or prolonged postures?

What other sports or hobbies are you involved in?

I agree that the information I have given on this form is true and correct.

Client Screening Questionnaire

Client Screening Questionnaire

Medical History

Current Exercise Regime

Physical Touch and Correction

Lifestyle

Client Screening Questionnaire