questionnaire-form – The Body Junction | Pilates, Yoga & Therapies in Bexhill

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The Body Junction | Pilates, Yoga & Therapies in Bexhill

Pilates, Yoga, Therapy, Physiotherapy

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Home
What We Offer/Timetable
Book a Pilates Class
About Us
Contact Us
Newsletter & Sign Up
- Newsletter
- Subscribe to Newsletter
Gift Vouchers

Questionnaire

Full Name *

First

Last

Email *

Date Of Birth (dd/mm/yyyy)

Occupation

Address + PostCode

Phone Number *

Subscribe To Our Mailing List? *

Yes
No

We occasionally send emails/newsletters relating to the classes and therapies we provide here. Do you wish for us to add your email to our mailing list? You can unsubscribe to this at any time by scrolling to the bottom of one of our newsletters and clicking 'Unsubscribe' within the email.

Doctor

Have You Done Pilates Before?

Yes
No

If yes, who with and how long for?

Do you do any of these?

Yoga
Aerobics

Do You Exercise? If so, what exercise do you do?

Have you had children. If yes, how many? Did you have a difficult birth? Can you engage your pelvic floor muscles?

Do you have an injury or current area of pain i.e. Back or Neck pain? (if yes, please specify where)

Have you had major surgery with the last year? If yes, when and what surgery was for?

Are you currently receiving treatment from a chiropractor, osteopath or physiotherapist? If yes, who?

Are you currently on any medication, or seeing a specialist for any reason?

Do you have high or low blood pressure?

Yes
No

Do you suffer with aches and pains in your bones or joints?

Yes
No

Are there any movements you know you can or should not do? (i.e. kneeling)

Are you able to lie on both sides?

Yes
No

Are you able to get up and down from the floor?

Yes
No

Can you lie on your back and your front?

Yes
No

How would you describe your health?

Do You Do Any Of The Following?

Sit with your feet up
Read in bed/watch TV in bed
Have long soaks in the bath
Sit on sofa with feet to one side
Cross your legs
Have your TV/computer screen to one side
Sleep on your tummy
Use a laptop

Where Did You Hear About Us?

What Do You Hope To Achieve From Doing Pilates?

What classes are you interested in joining? *

Induction/Beginner Classes
Mixed Level Pilates
Other Classes

Client Release Statement. I willingly participate in the practical exercises at my own risk. Despite any possible restrictions , disabilities or any predisposition to sickness or injury that may be aggravated or adversely affected as a result of my participation, I take full responsibility for any injury, loss or damage to my person or property that may arise directly or indirectly from my participation in the exercises. I will not seek to penalize, prosecute or claim compensation from the company for any injury, loss or damage. Signed: *

Date Signed *

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