Medical History

Surgical History - please list (with dates) all procedures and outcomes

Major accident/illness/trauma history – please list (with dates) any major illness, accident, fracture, major sprain and trauma

If you answered yes to any, please provide details

Are you currently taking any prescription medication or having treatment (physio, osteo, oncology). Please provide details

What are your general concerns regarding your movement/body? Aches, pains, niggles and injuries

If you are female, have you given birth? Provide details of births (dates, labour length, natural, C section) and any complications/problems during pregnancy or post-natal

Current Lifestyle

What is your occupation? Does it involve repetitive movements or prolonged postures?

How do you sleep?

Well – 7 hours most nights

Varies

Poorly. Insomnia

What is your typical exercise/activity/training pattern in a week?

Pilates experience

Complete beginner – never done it before

Some experience – been to a few classes

Experienced – advanced

What do you hope to achieve from my pilates classes?

How did you hear about Three Pillars of Health?

Signature

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Pilates Participation Informed Consent

All pilates programs begin at low level and will be advanced in stages depending on your fitness level. It is important for you to stop if experiencing feelings of fatigue and discomfort. There are dangers in overexertion - abnormal BP, fainting, fast or slow heart rhythm, stroke and heart attack. I have no conditions that would make me unsuitable for pilates.

Health Form

Medical History

Current Lifestyle