Intake Form

    Please Complete This Form Before Trying Yoga and Pilates. Please wait for us to give you a go-ahead before trying the exercises.

    Emergency Contact (Name and Mobile Number)

    Will this be the first time you have practiced Yoga or Pilates?

    Has you doctor ever said you have a heart condition or defect

    Do you feel pain in your chest when you do physical activity?

    Do you lose balance because of dizziness or do you ever lose consciousness?

    Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity?

    Do you have high blood pressure?

    If yes to the above is it controlled by medication?

    Have you had any major surgery in the last 10 years?

    Have you had any minor surgery in the last 2 years?

    Are there any movements that cause you pain?

    Are you taking any medications that affect your ability to exercise?

    Are you or could you be pregnant?

    Have you been pregnant in the last 6 months?

    Do you suffer from any of the following?

    If you answered yes to any of the above do you have permission to exercise?

    If you answered yes to any of the above please supply any information you deem appropriate.

    Describe your goals?

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