top of page

Initial Assessment Form

Physio & Pilates Clinic

Initial Assessment Form

Date Of Birth
Day
Month
Year

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

Reason for Attending

What brings you to Physio & Pilates today?

Pain & Symptoms (if applicable)

Do you currently experience pain or discomfort?
Yes
No

Past Injuries & Medical History

Please select all that apply

Current Health Information

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

Pilates & Movement Experience

Have you practiced Pilates before?
Never
Beginner
Intermediate
Advanced
If yes
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?
Yes
No

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
Unsure ( Need guidance)
Preferred session type:
1:1 Private
Duet / Semi-private
Small group
Combination of the above
Are you interested in a home or studio-based exercise plan?
Yes
No

Anything Else We Should Know?

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

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.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Please delete the signature (top right) and retry if the system does not accept it

Date
Day
Month
Year

Proceed to LOGIN to select your classes

Practitioner Notes (Internal Use)

            •           Postural observations:

            •           Movement assessment:

            •           Key restrictions / precautions:

            •           Initial plan & recommendations:

bottom of page