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.

Your name

Your email

Your Date of Birth

Emergency Contact (Name and Mobile Number)

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

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

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

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

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? YesNo

Do you have high blood pressure? YesNo

If yes to the above is it controlled by medication? YesNo

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

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

Are there any movements that cause you pain? YesNo

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

Are you or could you be pregnant? YesNo

Have you been pregnant in the last 6 months? YesNo

Do you suffer from any of the following?
Lung ConditionDiabetesEpilepsyArthritic JointsOsteoporosisOsteopoeniaBack PainNeck PainHypermobilityEye ProblemsDiagnosed with Mental Health ProblemAny other Joint ProblemsNone of the above

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

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

Describe your goals?