Bookings Essential Client Manager

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?^*

YesNo

Do you ever feel faint , dizzy or lose balance during physical activity/exercise?^*

YesNo

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?^*

YesNo

Do you ever experience unexplained pains or discomforts in your chest at rest or during physical activity/exercise?^*

YesNo

Are you currently pregnant?^*

YesNo

Has your doctor ever said that you should only perform physical activity recommended by a doctor and in the presence of a medically qualified professional e.g. physiotherapist?^*

YesNo

Have you ever been diagnosed with more than one chronic medical condition?For example you were living with heart disease and diabetes, or previously survived breast cancer and now have high blood pressure You would answer YES ^*

YesNo

Has a Doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes?^*

YesNo

If you have ticked 'yes' to any of the above conditions, it is recommended you seek guidance from an appripriate allied health professional prior to undertaking physical activity/exercise

ADHD and or Autism^*

YesNo

Arrhythmia /Atrial fibulation^*

YesNo

Cancer ( any and all types) ^*

YesNo

COPD or any lung condition ^*

YesNo

Coccyx Damage or Pain^*

YesNo

Developmental coordination disorder (Dyspraxia)^*

YesNo

Diabetes Type 1 or Type 2^*

YesNo

Ehlers Danlos syndrome^*

YesNo

Head injury/concussion/loss of consciousness^*

YesNo

High blood pressure^*

YesNo

Hypermobile joints^*

YesNo

Joint/Muscle Pain^*

YesNo

Knee Pain (Side, front or back) Low back pain^*

YesNo

Musculoskeletal pain ^*

YesNo

Osteopenia/Osteoporosis^*

YesNo

Weak pelvic floor or any Prolapse^*

YesNo

Psychological conditions e.g. Anxiety/Depression^*

YesNo

Sacrum or Sacroiliac Joint Pain (pain in the very lower mid back - top of buttocks)^*

YesNo

Shoulder injury/dislocations^*

YesNo

Separation of your abdominal muscles^*

YesNo

Spinal Surgery e.g. Disc, fusion^*

YesNo

spondylolisthesis (displaced vertebrae) ^*

YesNo

spondylolysis (stress fracture or defect in a part of the vertebra^*

YesNo

Please state any condition not listed above or declare that you have no medical condition which could affect your ability to exercise.^*

If you ticked 'Yes' to any of the above, please list details here. Is there any other information you would like your Classical Pilates UK teacher to be aware of?^*

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