Enrolment form
Class you wish to attend:
Name:
Address:
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Post Code:
Telephone:
Email Address:
Mobile:
Date of Birth:
Occupation:
Sports/Hobbies:
Does your occupation involve
any of the following?
Sitting
Driving
Bending
Standing
Lifting Heavy Weights
Any other repetitive action?
Has your doctor ever said that
you have any sort of heart trouble
or defect?
Yes
No
Have you arthritic joints or any bone
or joint problem that may
Yes
No
Are you pregnant, or had a baby in
the last 6 months?
Yes
No
Have you had any operations or
injuries in the last year?
Yes
No
Is there any other good reason not
yet mentioned that should sto
Yes
No
IF YOU HAVE ANSWERED YES
TO ANY OF THE ABOVE,
PLEASE GIVE RELEVANT
Do you suffer from backache?
Yes
No
If so, do you know why?
Please give details.
Is your blood pressure high,
normal or low ?
High
Normal
Low
Have you ever been given any
remedial exercises?
Yes
No
If so, can you briefly describe them?
Are there any movements that
cause you pain?
Have you been referred by a
specialist practitioner?
Yes
No
If yes, please state their
name and contact number:
What do you want to achieve
from your pilates sessions?
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