Client Assessment Form (Pilates NW Studio)

CLIENT ASSESSMENT FORM

Pilates NW Studio
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes or No.
Do you feel pain in your chest when you do physical activity?
Yes or No.
In the past month, have you had a chest pain when you are not doing physical activity?
Yes or No.
Do you lose balance because of dizziness or do you ever lose consciousness?
Yes or No.
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?
Yes or No.
Is your doctor currently prescribing you medication for your blood pressure or heart condition?
Yes or No.
Do you know of any other reason why you should not take part in physical activity?
If yes, please comment. What are your symptoms? Medical evidences (Scans; MRI; Orthopedic; Physio; Osteo; Chiropractor etc)
If you answered Yes to one or more questions: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.

If you have answered No to any of the questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.

I HAVE READ AND UNDERSTOOD AND ACCURATELY COMPLETED THIS QUESTIONNAIRE. I CONFIRM THAT I AM VOLUNTARILY ENGAGING IN AN ACCEPTABLE LEVEL OF EXERCISE, AND MY PARTICIPATION INVOLVES RISK OF INJURY.
Date

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Date
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CLIENT ASSESSMENT FORM