New Student Questionnaire

Please fill out the following form to help us understand your physical condition.
I will not pass your information to third parties and all submitted information is confidential in accordance to GDPR.

First Name

Email Address

Select an Address

Last Name

Date of Birth * required

Emergency Contact

Have you had any experience of Yoga or Reformer Pilates before ? Any other health of fitness activities you do?

Please check any of the following if they apply to you: * Required

Are you on any form of medication?

Any form of serious illness in the last 5 years including cancer

Any muscular or skeletal problems including arthiritis

Any digestive issues e.g. diabetes

Any cicrulation problems

Are you prone to colds

Have you ever had suffered from depression or other mental health ilnesses?

Do you smoke? If so how many a week?

Any gynaecological problems? Or are you pregnant/planning a pregnancy?

Any other issues you'd like to disclose?

Nothing to disclose

Please give details:

I declare that the info I’ve provided is accurate & complete

Initials

Today's Date

I accept terms & conditions

Thanks for submitting!

Donna Walton
Yoga & Reformer Pilates
@HOME Studio
77 Green Lane, BURNHAM SL1 8EG
donna@donnawalton.yoga
07766 062142

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