Pilates Questionnaire

Name*

First Last

Email*

Phone

What is your occupation?

Date of Birth

Describe your typical day*

eg. Are you standing/lifting/driving/lifting etc

Do you have any relevant medical conditions?

Please describe them in as much detail as you can (include recent or old) or n/a if not applicable)

If you are female are you currently pregnant?

If yes, how many weeks?

Have you engaged in Pilates prior to pregnancy?

If yes, please provide details

Have you had surgery within the last 2 years?

If yes, please provide details

Do you suffer from any of the following conditions?

Please tick any boxes that apply

If other , please state it here

Are you on any medications that we need to know about?

What is the name and address of your doctor/GP?

Have you ever had a DXA scan for bone density?

If yes, please let us know your T-scores and if you are on treatment or not

Are you presently attending any other types of therapy? Eg. Physiotherapy, Osteopathy, Chiropractic, Orthopaedic or Lymphatic message?

Please provide details

How would you describe your current fitness levels*

Have you ever had any past training in the Pilates method of movement?

If yes, please give details

What are your goals with your Pilates program?

Please tick all that apply

Other

How do you prefer to exercise?*

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