Health questionnaire

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Health questionnaire

We want to know you!

Full name

Age

Gender

ID Number

Cell

Contact person in case of emergency

Full name

Cell

Relation to you

Are you currently being treated by a Physiotherapist/Biokinetics/Chiropractor or any other health practitioner? May I contact them with your permission if necessary?

Name

Cell

Have you ever suffered from any heart or metabolic disease

Yes No

Has a doctor ever said your blood pressure is too high?

Yes No

Do you have any heart or respiratory diseases or problems?

Yes No

Has a health care professional recommended that you do NOT exercise?

Yes No

Have you ever had a condition that may be aggravated by exercise?

Yes No

Have dizzy or faint spells?

Yes No

Do you currently smoke?

Yes No

Do you currently have diabetes?

Yes No

Do you have raised cholesterol?

Yes No

Are you prenant?

Yes No

Are you more than 20% over your ideal body weight?

Yes No

Is there any reason not mentioned above that may prevent you take from taking part in physical exercise? If so, please specify below

Name of GP

Cell

Please list any serious surgeries

How many hours of sleep to you get?

How many hours do you spend sitting during the day?

Do you follow a healthy diet?

How much alcohol do you consumer per week?

Do you struggle to maintain a healthy weight?

Do you take any supplements or homeopathic medication?

What would you like to achieve out of your Pilates programme?

Please add any other information you feel is necessary for your instructor to know

The last step

As your last step, please complete this indemnity form and email it to us at info@lifemoovs.co.za

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