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Balance Pilates Pre Exercise Questionnaire

Please answer to your best ability. This will allow Balance Pilates to tailor the session to your needs.

First name

Last name

Email

Phone

Address

Birthday

Day

Month

Year

Emergency contact name and phone number

How did you hear about Balance Pilates?

Have you done reformer pilates before?

Do you have any injuries, aches or pains? (Recent or old)

Please describe exactly where the injury is located, what date the injury occurred and when it feels uncomfortable / when it feels good. Are you or did you receive treatment for this?

Are there any other health concerns?

e.g. asthma, epilepsy, spinal conditions, diabetes, high or low blood pressure, osteoporosis, arthritis, heart conditions, are you on any medications… please be as detailed as possible.

Could you be pregnant?

Yes

No

If you are pregnant what trimester are you in?

First (4-11 weeks)

Second (12-27 weeks)

Third (28-40 weeks)

Are you postpartum?

Yes

No

Unsure

Have you ever experienced a prolapse?

Yes

No

Unsure

Are you presently doing any types of therapy?

e.g. Massage, Physio, Chiropractic

Are you or were you active in any sports, exercise programs, physical activity? Please describe

Have you had any past training in the Pilates method of movement?If yes, where and did you achieve the results you desired?

What is your occupation? What does your typical day involve physically? e.g. sitting at computer, lifting...

What are your goals? What do you want most from this program?

Please specify any other information which may be relevant to your participation

I understand that I cannot join a Group Reformer class without having completed a One on One Initial Introduction with a Pilates Specialist first

I declare that the above information is correct and understand that it will remain confidential, except with my permission for the sharing of necessary information between Instructors within Balance Pilates Cashmere.

In an emergency, I give permission for Balance Pilates to seek medical attention for myself.

I confirm that all medical conditions that affect me are set out above.

I understand that the instructions given in my program are intended as professional guidance. If I become aware of any pain or discomfort during or after class, it is my responsibility to inform the instructor as soon as possible.

All reasonable care is taken by the studio to ensure my safety and enjoyment, however I take full responsibility for my own acts in the studio.

I acknowledge that the cancellation of an appointment is required no less than 24 hours for Private classes and no less than 12 hours for Group classes, before the scheduled time and that late notice will incur the loss of the session.

I understand that there are no refunds for unused sessions and sessions must be used within the expiration period.

Date

Day

Month

Year

Signature

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Balance Pilates Pre Exercise Questionnaire

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