Bookings Essential Client Manager

Mindful Body: Movement with intention - Create New Account

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First Name:*	Please enter First Name
Last Name:*	Please enter Last Name
Date of Birth:*
Mobile No.:*
Work No.:
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Emergency Information

Emergency Contact Name and relationship^*

D.O.B

Health Screening

Have or ever had this conditions? Arthritis, Asthma, Cancer, Cardiac Arrhythmia/Stroke, Degenerative joints, Osteopenia/Osteoporosis, Depression, Diabetes ,Epilepsy, Neurological condition, Lymphedema, Regular headaches, High or lower pressure, Hernia Vertigo, Major injuries/ operations/accidents, Other. Please give details.

If you are pregnant or if you have been pregnant in the last 12 month please give details of dates and any complications/concerns

If you have any relevant information (Medical, sport related or personal goals) that haven't been addressed in the health questionnaire and need to be raised during this consultation, please give more information.

What aspect of your health would you like to focus on, ore Stability, Flexibility, Posture, Strength, Stress Management or Relaxation?

What would you like to get out of our sessions? (eg. Pain management, workout, workshop, etc)

Have you done Pilates, Yoga or Strength and conditioning classes before? If yes, please give details.

Which of the props below do you have at home?

Do your daily tasks include performing the same movement regularly? Are they physically challenging or require you to be sitting/inactive for longs periods of time? Please give us details

Client Declaration

I confirm that all the information and details provided by myself (as the client) are true and I have provided an accurate representation of my physical and mental well-being *^*

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I declare that I have answered the above questions truthfully to best of my knowledge and should anything change I will immediately inform my instructor. ^*

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I understand that if injury or discomfort is to occur due to pre-existing reasons not identified in this document, that Mindful Body will not be held liable for any compensation, legal action or otherwise. ^*

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