Medical History & Consent Form Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Occupation Do you have or have you ever been treated for any of the following: * Heart Disease Arthritis Asthma or Respiratory Ailment Osteoporosis High Blood Pressure Low Blood Pressure Neurological or Muscular Disease (e.g. MS) Stroke None If you answered "Yes" to any of the foregoing, please identify any factors that may affect your performance in class or the type of instruction you would receive, including any relevant medications you might be taking and their side effects: Do you have any illness or condition not identified above that may affect your performance in class or the type of instruction that your recieve? * Please list any surgery/surgeries that you have had: * Do you have any injury or problem areas? If so, please provide details, including current treatment: * I agree that the above information is correct and understand that it will remain confidential except for the exchange of necessary information between instructors who may teach me. Should there be any changes in my condition or medication that that might affect my performance in class of the type of instruction I should receive. I will inform the instructor prior to class. I further understand that if I have not participated in an exercise program for some time or if I have an underlying condition, I should consult my medical practitioner before I begin class at Ascend, A Studio for Pilates. I understand that exercise may cause injury and accept that responsibility. I will inform the instructor and stop immediately should I feel dizziness, pain, or troubling sensation that suggests that I am not well or that the work is hurting me. * Date Signed * MM DD YYYY Thank you for filling out our Medical History & Consent Form!
