Enrolment Form
Title
First Name
Surname
Your address
Postcode
Email Address
Home telephone number
Mobile telephone number
Age
Occupation
Sports / hobbies
Emergency telephone no
Do your work/ pastimes involve?
Sitting for long periods?
Bending?
Lifting heavy weights
Driving
Standing
Any other repetitive action
Have you practised Pilates before?
No
Yes
If yes, where was it?
Studio? Where?
Mat classes? Where
At home with a DVD / video / book?
Other?
Number of classes attended
Please give details of locations etc.
Do you have any heart trouble?
No
Yes
If "yes" please give details
Are you pregnant?
No
Yes
If "yes", when is the baby due?
Have you had a baby recently?
No
Yes
How long ago?
Do you often have headaches?
No
Yes
Do you suffer from dizziness?
No
Yes
Is your blood pressure ?
High?
Normal?
Low?
Have you had surgery recently?
No
Yes
If "yes" please give details.
Do you suffer from?
Asthma?
Diabetes?
Epilepsy?
Have you been diagnosed with
arthritis in your joints?
any bone or joint problem
hypermobility
Do you suffer with back pain?
No
Yes
If "yes", please give details.
Do you suffer wtih neck problems?
No
Yes
If "yes" please give details.
Do you have pain or restricted movement
in your hip?
in your knee
in your ankle?
in your elbow?
in your shoulder
any other joint?
Are there movements that cause you pain?
No
Yes
If "yes", please describe them briefly.
Have you been referred by
GP
physiotherapist
osteopath
chiropractor
Other
Can I contact that practitioner?
Yes
No
Please state their name and telephone.
...and email address if known.
Why do you want to take up Pilates?
Date this form filled