HEALTH QUESTIONAIRE Download Paper Copy Name * First Name Last Name What specific health or fitness goals would you like to achieve at Maple Street Pilates? Prior Pilates experience? Yes No Where and what type? (mat, reformer, equipment, private, group) Medical History Do you now, or have you had in the past: History of heart problems, chest pain or stroke Yes No Increased blood pressure/low blood pressure? Increased blood pressure/low blood pressure? Yes No Diabetes or thyroid condition Diabetes or thyroid condition Yes No Any chronic illness or condition Any chronic illness or condition Yes No Difficulty with physical exercise Difficulty with physical exercise Yes No Any physical restrictions given by a PT or physician Any physical restrictions given by a PT or physician Yes No Recent surgery (last 12 months) Recent surgery (last 12 months) Yes No Pregnancy (now or last 3 months) or C-section births Pregnancy (now or last 3 months) or C-section births Yes No Muscle, joint, or back disorder Muscle, joint, or back disorder Yes No Any previous injury still affecting you Any previous injury still affecting you Yes No Hernia or any condition aggravated with weight resistance Hernia or any condition aggravated with weight resistance Yes No Please elaborate on any ‘yes’ answers: Physical History List any injuries and/or any significant medical treatments. Please check all body parts that are involved and where appropriate. Head/Neck Shoulder/Arm Ribs/Abdomen Upper/Mid Back Lower Back Hip/Pelvis Knee Ankle/Foot Please elaborate on any of the above: What are the physical demands of your occupation? Primary fitness, sports, and recreational activities: Do you now, or have you had in the past: History of heart problems, chest pain or stroke? Yes No Thank you!
