Health Screening Form

General Details
Doctor details
Emergency Contact
Aims & Goals

Please select as many as you feel appropriate

Lifestyle
Activity

Please select all that apply

Smoking
Medical History

If you are currently attending a physiotherapist / osteopath / chiropractor for any kind of treatment, please specify the name of your physiotherapist / osteopath / chiropractor and the name of their practice. With your permission, we would prefer to make contact with them prior to you commencing classes / one-to-one sessions:

Client Release Statement

I understand the above questions and I have answered to the best of my knowledge. I agree that I am in good physical condition (except as stated above) and accept that I exercise at my own risk. I understand that whilst the utmost of care is taken, that neither individual instructors, InspireFit or KM Pilates will be liable for any damage or injury.

By typing your name here you are signing this document

Date form completed

All information given is strictly confidential