Health History
Name ___________________________________________________
Address __________________________________________________
City________________________________________Zip___________
Phone Numbers _____________________________________________
Email ____________________________________________________
Birth date __________________ Age ____________
Emergency Contact __________________________________________Realtionship to You:_______________________
How did you hear about us ? ____________________________________
What is your goal in coming to Pilates of Fayetteville?_____________________
1. Has your doctor ever said that your blood pressure was too high or too low?
_____________________________________________________
2. Do you have diabetes? ___________________________________
3. Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc.)? _______________________________________________
4. Has your doctor ever told you your cholesterol level was too high? ____________________________________________________
5. Do you have any injuries or orthopedic problems (bursitis, bad back, bad knees etc.) please be specific? _________________________________________________________
6. Are you pregnant? ______ How far along?_____________Are you post-partum less than six weeks? ______
Have you delivered in the last 12 months?___________ Date_______________ Vaginal or C-section_____________
7. Do you often feel faint or have spells of severe dizziness? _______________
8. Do you experience extreme breathlessness after mild exertion? __________
9. Has your doctor ever said that you have bone or joint problems, such as arthritis or osteoporosis that can be aggravated or made worse by exercise? ________________________________________________________
10. Do you have any other medical conditions or problems not previously mentioned?
______________________________________________________
11. Do you know of any other reason why you should not do physical activity?_______________________________________________________
12. What is your current exercise program?____________________________________________________ ____________________________________________________
I have completed this health history to the best of my ability and have not knowingly withheld any information concerning my health history. I acknowledge to the best of my ability that I am in good health and have no known problems that would restrict my ability to participate in this exercise program. I will notify the instructor if I am made aware of any changes in my health history, or my current health situation.
Signed _____________________________________ Date________