Health Formhello@beyondmove.com First name Last name Email address Mobile Birthday Emergency contact name and number What are your goals? Core Stability Reduce Back Pain Flexibility Posture Recovery after injury/surgery Relaxation Toning Women Health/Pelvic Floor issues Other What prompted you to take up Pilates with Beyond Move? Have you had any recent injuries or surgery? If so, please provide details below Are you currently experiencing, or have you ever been diagnosed with any of the following medical conditions? Back Pain Muscular or joint conditions such as Hypermobility, Arthritis, EDS Pain at the back or front of the Pelvis Heart conditions/problems Balance and/or coordination issues Blood Circulation Issues High or Low Blood Pressure Any neurological conditions Osteoporosis Dizziness/Ear or hearing difficulties Epilepsy Diabetes Anaemia None of the above Are you doing any other sports or physical activities? If so, please provide brief details below Are you currently working? If so, what is your occupation? Does your occupation involve any repetitive movements or prolonged posture? If so, please provide brief details below Has your GP/Consultant/Midwife agreed for you to carry out gentle exercises? Yes No Data consent. I consent to Beyond Move Ltd collecting and holding my personal and health information, including my medical history, injuries and any conditions disclosed in this form. I understand this information is used only to make sure my sessions are safe and suitable for me. It will be stored securely, seen only by the Beyond Move teachers involved in my sessions, and not shared with anyone else except where necessary for my care or in an emergency, and I can withdraw this consent at any time by contacting hello@beyondmove.com. Our full privacy policy is at beyondmove.com/privacy-policy. I consent: Yes No Pilates participation informed consent. I have answered these questions to the best of my belief. I will inform my teacher if my medical condition changes in the future: Yes No
