HEALTH SCREEN

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of birth *

MM

DD

YYYY

Previous Pilates experience *

Experienced

Novice

None

General Health *

Excellent

Good

Fair

Are you currently or have you previously been diagnosed with any of the following (please select)?

Heart attack

DVT/PE

Cancer

Heart disease

Dizziness

High blood pressure

Diabetes

Numbness or weakness

Osteoporosis

Osteopenia

Osteoarthritis

Rheumatoid arthritis

Pregnancy (in the past and current)

Epilepsy

Stenosis

Thyroid Disorder

Shoulder impingement

Back pain

Herniated disc

Bowel/Bladder issues

None

How did you find out about Adjust Pilates (please select)?

The New Woodend Star

Web search

Word of mouth?

Walked past and saw signage