Health Questionnaire - The Serenity Barn

First Name *

Last Name *

Street Address *

Apartment, suite, etc

Town/City *

County/Province *

Post Code *

Date of Birth *

Occupation *

Telephone *

Email Address *

1. Please chose when appropriate

Arthritis *YesNo

Asthma *YesNo

Diabetes *YesNo

Epilepsy *YesNo

Osteoporosis *YesNo

Back problems *YesNo

Eye problems *YesNo

Heart condition *YesNo

Hearing difficulties *YesNo

Balance disturbance *YesNo

Stroke *YesNo

Whiplash *YesNo

If 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 *YesNo

if YES please specify *

3. Have you been pregnant in the last 12 months? *YesNo

Details of pregnancy *

4. Are you currently taking any medication prescribed by your doctor? *YesNo

if YES please specify *

5. What is your experience with Pilates/Yoga? *

6. What would you like to achieve from your Pilates/Yoga sessions? *

7. Is there any other relevant information that has not yet been mentioned that should stop you performing physical exercise?

8. Please complete your next of kin:

Contact Name *

Telephone *

9. How did you hear about us? *

10. 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. Please do not park too close to the driveway as this restricts people entering/leaving Bascote Chase. Also please do not park on the grass verge in front of Bascote House.

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. *

Agree