KW Pilates
 
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Please fill the form below before your first class.

Medical History

This information will be treated confidentially

* Name
* Date
Please answer yes or no to any of the following conditions you currently have or have had in the past
* Heart attack, heart disease, cardiac surgery
* Asthma or other respiratory ailments
* Migraines or recurrent headaches
* Neurological or muscular disorders e.g. Multiple Sclerosis
* Arthritis, Rheumatoid, Osteo or other
* Light-headedness or fainting
* Swollen, stiff or painful joints
* high blood pressure
* Low blood pressure
* Stroke
* Diabetes
* Hernia
* Epilepsy or seizure
* Accidents
* Bursitis
* Kidney disease
* Osteoporosis
* Anemia
* Fractures/dislocations
If you marked yes to any of these conditions, please write the details in the textbox below. Include details about any medications you are taking and if there are any side effects as these could influence your performance in class or the types of classes you should receive.
information
Details
* Do you have any conditions, illness, disease or any other medical condition not outlined above, as this may affect either your performance in class or the type of class you should receive.
If yes, please explain
* Are you pregnant now or have you been in the last three months?
* Have you had surgery or been hospitalized in the last two years?
* Do you have an injury or problem area e.g. neck, shoulders, low back?
If yes, please explain

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KW Pilates. 112 Wellington St. N., Kitchener ON
N2H 5J8
TEL: 519.883.3999
EMAIL: office@kwpilates.com