Health History Form
Your Name & Phone Number: *
Your answer
Emergency Contact's Name & Phone Number:
Your answer
Today's Date:
MM
/
DD
/
YYYY
Describe any physical activity you do somewhat regularly:
Your answer
Describe any physical activity you wish to take part in the near or distant future:
Your answer
What type of movement do you enjoy?
Your answer
What type of movement do you dislike?
Your answer
Please check the "YES" box if you have experienced any of the following in the past or present:
YES
Heart Disease
High blood pressure
Stroke
Dementia / Cognitive disability
Neurological Disorders (MS / Parkinson's / ALS)
Glaucoma
Vertigo
Epilepsy
Breathing or lung problems
Diabetes
Pregnancy within the last 3 months
Surgery within the last 12 months
Osteopenia / Osteoporosis
Herniated Disc
Spinal Stenosis / Spondylolisthesis / Facet Joint Syndrome
Scoliosis
Muscle Sprain / Strain
Bone Fractures
Bursitis / Tendonitis
Arthritis (Osteoarthritis / Rheumatoid)
Joint Injury (Shoulder / Hip / Knee)
Joint Replacement Surgeries
Peripheral Neuropathy
SI Joint Dysfunction
Please list any questions, concerns and/or goals for your Pilates practice.
Your answer
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