New Client Registration

Name *

First Name

Last Name

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

2. Do you ever feel pain in your chest when you do physical activity? *

Yes

No

3. Have you ever had chest pain when you were not doing physical activity? *

Yes

No

4. Have you had a stroke? *

Yes

No

5. Do you ever feel faint, have spells of dizziness or lose consciousness? *

Yes

No

6. Do you have a spinal or orthopaedic condition that could be made worse by exercise? *

Yes

No

7. Do you have a neurological condition? *

Yes

No

8. Have you ever been told that you have high or low blood pressure? *

Yes

No

9. Are you (or is there any possibility that you might be) pregnant or have had a baby in the last 6 months? *

Please get in touch with Alex for a Pre/Post Natal Form

Yes

No

10. Do you have asthma or have ever suffered from shortness of breath at rest or with mild exertion? *

Yes

No

11. Do you have Diabetes? *

Yes

No

12. Have you ever practiced Pilates before? *

Yes

No

13. Have you been referred to Pilates by a health professional (eg Physiotherapist, Chiropractor, GP)? *

Yes

No

14. Are you currently taking any medication which the instructor should be made aware of? *

Yes

No

15. Have you had any recent injuries you feel the instructor should be made aware of? *

Yes

No

16. Have you had any surgeries which you feel the instructor should be made aware of? *

Yes

No

17. Have you been diagnosed with or had treatment for Rheumatoid/Osteo Arthritis or Osteopenia/Osteoporosis? *

Yes

No

From time to time AM Pilates London would like to send you emails including offers, news, class timetable updates. Please select below whether you would like to receive these. *

Yes

No

By inputting my name below I confirm that I have read, understood and accurately completed this questionnaire, and that where necessary I have sought appropriate medical advice & approval to exercise. I agree to update this on an annual basis, and I have read and agree to AM Pilates London Terms and Conditions. I realise that by participating in a Pilates class I may be at risk of injury and I hereby confirm that I am participating voluntarily. *

I confirm