Pilates Plus+
Increase your well being with Pilates Plus treatments
PERSONAL INFORMATION SHEET
Last Name:______________________________First Name:__________________________
Address: __________________________________________________________________
Town:_________________________________City:________________________________
County:______________________________Post code: _____________________________
Birth Date:_____/______/______
Contact Information
Work phone: ( )________________________
Home phone: ( )________________________
Mobile: ( )________________________
Fax: ( )________________________
Email address: _______________________________
Emergency Contact
Name:__________________________________Relationship:__________________________
Phone: ( )__________________________Alternate Phone: ( )___________________________
Additional Information
How did you find out about us? _____________________________________________________
Do you have any injures aches, pains? (Recent or old) Please describe them (if you need room please write this on page 2)
_______________________________________________________________________________
_______________________________________________________________________________
Are thee any other health concerns e.g. Asthma , High blood pressure?
_______________________________________________________________________________
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Do you do any other forms of exercise / or have you within the last year?
_______________________________________________________________________________
_______________________________________________________________________________
Have you had any past training in the class you are attending (Pilates, Yoga, Tai Chi)? If yes where?
_______________________________________________________________________________
_______________________________________________________________________________
What is your occupation? Does it involve lifting/ sitting at a computer etc.
_______________________________________________________________________________
_______________________________________________________________________________
What would you most like to achieve from your sessions?
_______________________________________________________________________________
_______________________________________________________________________________
OTHER INFORMATION:
_______________________________________________________________________________
_______________________________________________________________________________
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Please return to
THE FITNESS CLINIC
109 Humber Road
London
SE3 7LW
and make cheque payable to Galina Bell OR Pilates Pluss
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