Client Enrolment/Health Screening QuestionnaireAll information will be treated in the strictest of confidence. Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Email * Mobile * Emergency name & contact number How did you hear about these classes? * Do you have any previous experience of Pilates? Were you referred by a health practitioner or therapist? If yes, by whom? Please cross any of the following conditions which affect you HIGH/LOW BLOOD PRESSURE DIABETES EPILEPSY HEART DISORDER RESPIRATORY PROBLEMS ARTHRITIS OSTEOPOROSIS NECK OR BACK PROBLEMS HEADACHES DIZZINESS FAINTING Please provide any further information about the above conditions or any other conditions which you think I should be aware of Are you pregnant? Yes No Or have you given birth in the last 12 months? If yes, please write date of birth MM DD YYYY Liability Waiver: I hereby state that I have read, understood and answered honestly the pre-exercise Health Screening questionnaire. Whilst I understand that every effort is made to keep the class safe and enjoyable, I am participating in the class of my own free will and as with any exercise programme, I understand that there is a risk of injury. In the event of any such injury, I will not hold Beyond Pilates London responsible. I have read and agree to the terms above. * First Name Last Name Date * MM DD YYYY Thank you!