Pilates. Strength. Nutrition. Mindful Movement.

Forms

Client Health Questionnaire

Please complete this before your first session. It helps Melanie keep your sessions safe and tailored to you — everything you share here is confidential.

Prefer to fill this in by hand? Print a blank copy and bring it to your first session instead.

Client information
Have you ever had, or do you have…?

Please answer every question.

High blood pressure
High cholesterol
Pain / tightness in chest
Rheumatic fever
Heart / stroke condition
Gout
Stomach / duodenal ulcer
Liver / kidney condition
Diabetes
Epilepsy
Do you experience, or have you ever experienced…?

Please answer every question.

Family history of heart disease, stroke or raised cholesterol in relatives under 65?
Breathing difficulties or asthma
A hernia
Muscular pain / cramps
Are you dieting or fasting?
Are you pregnant, or have you given birth in the last six weeks?
Have you had any major injuries in the following areas?
Do you have any conditions that may be reason to modify your exercise program?
Your goals
Consent

I understand that all due care will be taken by Nourish & Move for Wellness regarding my exercise program. I also understand that the above information is confidential and to be used as a guideline to the limitations of my ability to exercise. I will not hold the staff or business Nourish & Move for Wellness liable in any way for any injuries that may occur during or after my participation in the exercise program. I will also notify Nourish & Move for Wellness if any of the above information changes.