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Authentic Pilates

Client Health and Pre-Assessment Form

Birthday
Day
Month
Year

e.g. desk work, lifting, caring, sport

Emergency Contact Details

Reason for Attending

What brings you to Physio & Pilates today?

Pain & Symptoms (if applicable)

Do you currently experience pain or discomfort?
No
Yes

Past Injuries & Medical History

Please select all that apply

Current Health Information

Are you under medical care?
No
Yes
Are you taking any medication?
No
Yes
Have you been advised against exercise by a healthcare professional?
No
Yes

Pilates & Movement Experience

Have you practiced Pilates before?
Never
Beginner
Intermediate
Advanced
What Type
Mat Pilates
Reformer
Other apparatus
How long did you practice Pilates for?
< 6 months
6–12 months
1–3 years
3+ years
Have you ever worked with a Physiotherapist or clinical Pilates teacher before?
No
Yes

Physical Activity & Lifestyle

Current activity level:
Sedentary
Light (walking, gentle exercise)
Moderate (2–3xweek exercise)
High (sports/training)

Personal Goals

What would you most like to achieve through Physio & Pilates?

Ideal Frequency & Commitment

How often would you ideally like to attend sessions?
1x per week
2x per week
3x per week
Fortnightly
Preferred session type:
1:1 Private
Duet / Semi-private
Small group
A combination of both
Would you be interested in live online classes?
No
Yes

e.g. fears, previous bad experiences, expectations, pregnancy, hypermobility

Consent & Declaration

  • I confirm that the information provided is accurate to the best of my knowledge.

  • I understand that Physio & Pilates involves physical movement and I agree to inform my practitioner of any changes to my health.

Date
Day
Month
Year
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