Client Questionnaire for Trigger Point Pilates

Please complete the following carefully. All details will remain confidential.

First Name *

Last Name *

Date of birth *

Contact Telephone Phone Number *

Email *

Occupation *

Number of Children *

Relationship Status *

GP Name *

GP Telephone Number *

How active is your lifestyle? How often do you train? What is your current exercise/sport activity? *

Do you have a recurring old injury? Or suffer from chronic pain? If so, please state: *

Are you taking any medication? If so what? *

Are you taking supplements? *

If you said yes to taking supplements, please state which (type NA if not) *

What kind of diet do you have *

Can you relax? Do you make time to relax? How well do you sleep? *

What are your current stress levels? *

Do you suffer from Headaches/Migraines? *

Are there any other conditions currently being treated by your GP? *

What is your past injury?/accident history? *

Do you suffer from a chronic painful condition? If yes please give details *

Do you suffer from dizziness/fainting? *

Have you recently had a kidney/bladder infection? If so when: *

Do you suffer from any skin allergies or contagious skin rashes? If so, please state: *

Have you recently suffered from or do you suffer from any of the following?:

Please tick any conditions that are relevant to you...

Tiredness/ ME

Breathing Conditions

Asthma

Hayfever

Chronic Cough

Sinus Problems

How many children have you had? *

How many pregnancies have you had? (type NA if not applicable) *

Did you have any difficulty with delivery? (type NA if not relevant) *

Have you ever had a C-Section *

Since having children, have you had chronic pain in the back/hips/pelvis/shoulders/ neck? Please give details. (type NA if not applicable) *

Women only - Do you consider yourself to be

Women only - Are you still having regular periods?

I have read the above and confirm that I do not suffer from any other conditions that may prevent me from attending a TPP class. I will keep my instructor informed of any changes in my health.

Signature *

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Date of signature *