First Name *Last Name *Street Address *Apartment, suite, etcTown/City *County/Province *Post Code *Date of Birth *Occupation *Telephone *Email Address *1. Please chose when appropriateArthritis *YesNoAsthma *YesNoDiabetes *YesNoEpilepsy *YesNoOsteoporosis *YesNoBack problems *YesNoEye problems *YesNoHeart condition *YesNoHearing difficulties *YesNoBalance disturbance *YesNoStroke *YesNoWhiplash *YesNoIf you have answered yes to any of the above please specify:If you have answered YES to one or more questions please talk to your doctor about this exercise program and follow his/her advice.2. Have you had any other health problems, injuries or operations in the last 12 months *YesNoif YES please specify *3. Have you been pregnant in the last 12 months? *YesNoDetails of pregnancy *4. Are you currently taking any medication prescribed by your doctor? *YesNoif YES please specify *5. Class type booked *YogaPilatesOther6. What is your experience with Pilates/Yoga? *7. What would you like to achieve from your classes? *8. Is there any other relevant information that has not yet been mentioned that should stop you performing physical exercise?9. Any other comments?10. Please complete your next of kin:Contact Name *Telephone *11. How did you hear about us? *Choice of teacher *Amy BellLouisa FordNatalie McMahonJames BellVerity ThompsonSam PratteyNot sure12. Would you like to subscribe your above email address to The Serenity Barn newsletter? *YesNoYou will be automatically subscribed to our newsletter upon selecting ‘yes’I agree to the Parking Policy: *I AgreePlease park on the white gravel drive or alternatively on the roadside near the barn. When parking on the roadside please be mindful not to block the pavement. One wheel on the pavement is fine, just not blocking the walk through as we have wheelchair & pushchair users in the village. Please also ensure you do not block or restrict tractor access to the horse field.GDPR *YesI agree to my personal details being held by The Serenity Barn. We confirm we will not sell or share any personal details. It is your responsibility to inform the teacher of any changes that may affect your exercise program such as: If your doctor (or any other health practitioner) advises you on health grounds not to exercise If any important medical details change It is also your responsibility: To observe instructions on safety, technique, performance and use of equipment I have read, understood and completed this questionnaire. My questions have been answered honestly to the best of my knowledge. *AgreeSubmit