Health Questionnaire & Assessment Form

  • General Details
  • Pilates Aims
  • Lifestyle
  • Medical History
  • Consent


Gender:*



Which levels are you interested in?*

Have you done pilates before?*

Which aspects of your health would you like to concentrate on?*







Are you currently experiencing any of the following conditions?













Have you undergone any recent surgery or have any other medical conditions not mentioned here?

Are you currently experiencing any of the following conditions?









What type of delivery was it?*
Have you ever had any caesareans prior to this birth?*

Are you currently experiencing any of the following?





Have you had twins/triplets etc?*
Have you ever had complications during pregnancy?*
Have you ever suffered from pelvic girdle pain?*
Have you ever had an episode of low back pain during pregnancy?*
Have you had episodes of back pain outside of pregnancy?*

I declare that I have read the Medical Questionnaire thoroughly and understand its content. I have completed this questionnaire to the best of my knowledge and have not withheld any specific information requested by it. Any questions I have had regarding the contents and purpose of this medical questionnaire have been answered to my full satisfaction. I consent to an introductory assessment and I understand that a degree of undress may be during this and that the therapist will explain this to me at the time. I understand that the Pilates programme will begin at a low level and will be advanced in stages depending on my fitness level. I understand and agree that the therapist or I can stop the exercise session at any time if I am or are seen to be experiencing any symptoms of fatigue or discomfort. I understand and am aware that there exists the possibility of certain dangers when exercising. These can include abnormal blood pressure, fainting, and irregular, fast or slow heart rhythm and in rare instances a heart attack, stroke or death. I understand (a) whilst every care will be taken it is impossible to predict the body’s exact response to exercise and (b) every effort will be made to minimise these risks by evaluation of preliminary information relating to the questionnaire and fitness by observation during exercise. For one to one sessions, I understand that the Pilates program will be specifically designed as a personal training plan and will take into account details about me given in my questionnaire and assessment. I understand that this programme of exercise should only be undertaken when I have been given specific instructions to exercise on my own. For class sessions, I understand that the Pilates programme has been put together to cover a more general plan and not specifically designed as a personal training plan for me. Therefore I understand that the programme of exercises should only be undertaken in a Pilates class. Further I understand and agree that if I perform any of the exercises outside the class then I do so at my own risk. I agree that you or your authorised agent shall not be liable for injuries I suffer in respect of: Pilates exercises I perform outside a Pilates class or one to one session; Pilates exercises performed otherwise than in accordance with the instruction given by you or your duly authorised agent; and/or Performing Pilates exercises if I am suffering from an injury or ailment of which I have not informed you. Please note that a full fee may be applicable if less than 24 hours notice is not given for all one to one sessions or One week notice for cancellation for block of classes.

If you are experiencing problems completing this form please click here to download an offline version. Please fill out the form and then email it to info@pilatesbyphysio.com or alternatively post it to FAO Justine McLaughlin, 184-200 Pensby Road, Heswall, Wirral, CH60 7RJ.