Bookings Essential Client Manager

Were you referred by a Medical Practitioner or Allied Health Professional:^*

YesNo

Referral contact details. If you'd like us to know or touch base with your referring practitioner please provide the details below so we can make contact in regards to your health history.

MEDICAL HISTORY - Please be sure to complete all the questions pertaining to your medical history. Have you or OR are you currently experiencing any of the following? Select all that apply. If you have ticked a boxed please provide more details.

GP or Allied Health advice not to exercise^*

YesNo

Any chronic illnesses or conditions (tinnitus/migraines/chronic fatigue etc)^*

YesNo

History of heart problems^*

YesNo

History or High or Low Blood Pressure^*

YesNo

Smoker (cigarettes, vape etc),^*

YesNo

History of breathing conditions (asthma/lung conditions)^*

YesNo

Diabetes or thyroid conditions^*

YesNo

Epilepsy (seizures)^*

YesNo

Wear or have worn orthotics or any type of brace^*

YesNo

History of school age illnesses or conditions (EBV/Glandular fever etc)^*

YesNo

History of mental health (e.g. postnatal depression, anxiety))^*

YesNo

Do you suffer allergies that require use of an Epipin^*

YesNo

History of Cancer^*

YesNo

Are you or could you be pregnant^*

YesNo

Please provide as much details as possible to any conditions you have selected above. If you are Pregnant please advise the number of weeks, due date and any medical conditions. If you are Postpartum within 1 year of last birth please advise previous complications/conditions and birth history including type of delivery.

Please list your history of injuries, surgeries and accidents:^*

Please list any areas of pain or discomfort:

Have you practiced Pilates before?^*

YesNo

If yes, can you provide more information of the type of Pilates (EG. Mat, Reformer, Studio, other)

Why have you decided to commence Pilates? (EG. Rehabilitation, Core strength / Stability, Posture, Toning & Strength, Health & Wellbeing, Mobility, Sports Performance, other)

Tell us a little more about your Lifestyle. What occupation, type of work/study are you currently engaged in or trained to perform?

What other exercise, sports and hobbies are you involved with?

Informed Consent / Waiver of Liability I declare that I have read the Initial Client Intake + Health history and have completed it to the best of my knowledge^*

YesNo

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