Welcome to Natasha Ann Pilates.  This is a private and confidential questionnaire designed to assess your capabilities and enhance safety concerns with all classes.

YOUR PERSONAL DETAILS
Name:	Date of birth:

Email:	Telephone/Mobile:

Address:

Postcode:

YOUR EXERCISE BACKGROUND & FITNESS GOALS
When did you last exercise and what was it?:

What are your goals by attending this class/session?

YOUR HEALTH
Have you ever had, or are you currently seeking treatment by a medical practitioner for any of the, any of the following ailments? Please tick as appropriate:

Arthritis or rheumatism

Stiffness or pain in your neck

Pain in your knees?

Hernia

Heart disease

High blood pressure

Asthma, emphysema or bronchitis

Backache or  scoliosis

Orthopedic conditions

Diabetes	Raised cholesterol levels
•	If you have checked any of the above please explain

Any other chronic illness/health problems? Please give details:

Where did you hear about us? Please give details:

TERMS & CONDITIONS
*By signing this form, you acknowledge that:
•	You are voluntarily choosing to participate in a physical exercise program	 	     	
•	
•	You agree that any information, instruction or advice obtained from Natasha Ann Pilates will be used at your own risk.
•	You agree that any information, instruction or advice obtained from Natasha Ann Pilates may NOT be used as a substitute for your doctor’s advice or treatment.
•	You agree to release and discharge Natasha Ann Pilates from any and all responsibilities or liabilities from injury arising from your participation in any exercise program designed by Natasha Ann Pilates on your behalf.

*Your signature	Date
I HAVE READ AND CLEARLY UNDERSTOOD THE TERMS & CONDITIONS
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