Medical Questionnaire

Pilates Canberra New Acton and Barton Medical Screening Questionnaire

In order to prepare for your initial session with your Pilates Canberra Instructor we ask that you fill in the following medical questionnaire and return it to us prior to your initial session.

Your medical questionnaire responses will be strictly confidential but will allow us to prepare for your session. If you have questions at any time about the questionnaire please contact [email protected] or call on 02 62817788; if you require information from the Director of Pilates Canberra Pty Ltd, please contact [email protected]

Contact Information

First Name :
Last Name :
Phone :
Email Address :

Medical History: Please tick and fill in details if you have been diagnosed with any of the following:

Organ or blood conditions: heart, lungs, liver, kidneys, etc:

Special condition: diabetes, epilepsy, auto-immune (like RA, post viral syndrome, chrones, etc)

Surgery history:

Skeletal - Muscular History: Please tick and fill in details if you have been diagnosed with any of the following

Skeletal breaks or abnormalities:

Joint dislocations, repairs, replacements:

Muscle strain or injury:

What do you want to gain from your Pilates instruction?

How did you hear about Pilates Canberra at New Acton or Barton?

What other physical activity do you do weekly and detail frequency and length of each session time:

I have answered this questionnaire to the best of my knowledge and with honesty to enable safe and effective advice to be offered by your Pilates Assessor - please sign in agreement of this statement: