Berrylands Pilates

Health Questionnaire Form 

The following information is to ensure the exercise is as safe and appropriate for you as possible. Please read the questions carefully and answer each one honestly. (All answers will be treated in the strictest of confidence).

Do you have or have you ever had a known heart condition e.g. heart attack, stroke, abnormal ECG, heart palpitations?
Do you ever feel pain in your chest when you exercise or do physical activity?
Do you have, or have you ever had a bone or joint condition that could be made worse by exercise or that could prevent you from exercising?
Do you have high blood pressure?
Do you have any other medical conditions not mentioned (e.g. Asthma, Diabetes, Epilepsy, Hernia, Dizziness, Circulation problems)?
Are you currently taking any prescribed medication?
Do you have any other medical conditions not mentioned (e.g. Asthma, Diabetes, Epilepsy, Hernia, Dizziness, Circulation problems)?

Thanks for submitting!

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