Pilates with Krissie 
Your Pre Pilates Session Screening form
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Email *

Your name


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Your date of birth


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Your phone number *
Emergency name & contact number
(emergency contact details will only be used in the event of a personal emergency during a class). 
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Do you have chest pain when performing physical activity?

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Do you have a heart condition?

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Do you suffer from high or low blood pressure?

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Do you have a bone or joint problem that could be aggravated by physical activity?

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Please give details if you answered yes to the above

Have you had recent surgery?

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Are you pregnant or have you given birth in the last 6 months?

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Do you ever have spells of dizziness or feel faint?

*

Do you have any other medical conditions or injuries?  (i.e. diabetes, high blood pressure, high cholesterol, arthritis, osteoporosis, asthma, epilepsy, back problems etc.)?

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