Pilates for Equestrians Health Screening Form

Please print, fill out and bring to your first session.

Age:

Gender:

Occupation:

Have you ever been treated by a physician for?

____ Heart disease

____ High blood pressure

____ Gastric reflux

____ Glaucoma

____ Orthopedic/joint (shoulder/elbow/spine/knee) problems

____ Osteoporosis

____ Arthritis

____ Peripheral neuropathy (numbness/tingling/diminished senses)

Are you pregnant? ____ Prior deliveries? ____

Prior surgeries ______

Prior injuries ____

Do you carry a list of current medications?

Activity level/exercise frequency:

Prior movement experience? (dance, yoga, Feldenkrais etc?)


What are your fitness goals?



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In the unlikely event that class is cancelled, please provide the best phone number or email address to contact you at:

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Participants signature                                      Print full name


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Date

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Emergency contact number

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