Name *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Do any of these health conditions apply to you? *

Please tick all boxes that apply.

High blood pressure

Low blood pressure

Arthritis

Diabetes

Epilepsy

Heart problems

Asthma

Detached retina/other eye problems

Recent fractures / sprains

Recent operations

Back problems

Knee problems

Neck problems

Hypermobility

Recent injuries

Recent pregnancies

Are you pregnant or breastfeeding?

Perimenopausal

Menopausal

Stress

Anxiety

Depression

NONE OF THE ABOVE

I take full responsibility for my health and wellbeing during any sessions with AIM PILATES, including any injuries or illnesses. *

Yes

No

Date *

MM

DD

YYYY

Signed (Print Name) *

First Name

Last Name