Medical Questionnaire Medical Questionnaire Step 1 of 3 33% Name* First Last DOB DD MM YYYY Email* PhoneAddress* Street Address Address Line 2 City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Name* First Last Please provide a contact name and number for use should an emergency arise during a Zoom session.Emergency Contact Phone* Have you ever suffered from heart trouble?*NoYesPlease give detailsAre you presently taking any form of medication?*NoYesPlease give details (name and what it's for)Do you suffer from chest pains?*NoYesPlease give detailsDo you ever have spells of dizziness or feel faint?*NoYesPlease give detailsHave you ever had either high or low blood pressure, and/or high cholesterol level?*NoYesPlease give detailsHave you ever had asthma, chronic bronchitis or any other chest ailments?*NoYesPlease give detailsDo you suffer from back pain or any orthopaedic problem?*NoYesPlease give detailsDo you suffer from severe headaches or migraines?*NoYesPlease give detailsAre you recuperating from a recent illness/operation or injury?*NoYesPlease give detailsHave you any medical condition that we should be aware of or have you ever been told not to exercise for any reason?*NoYesPlease give detailsAre you pregnant or have you given birth in the past 6 months?*NoYesPlease give detailsIs there any history of heart disease in your immediate family (under the age of 55)?*NoYesPlease give details IMPORTANT: If you answered YES to any of questions above, you are advised to seek medical advice/approval before commencing any exercise or exercise programme. Please note that taking part in the exercises provided by Lucy-Pilates, on the website or via the Facebook group, should be considered an unsupervised workout and because it is unsupervised, it is NOT suitable for rehabilitation after surgery or injury. I have been informed in writing that if I answer YES to any of questions on this questionnaire, I should seek medical advice/approval before commencing any of the exercises offered by Lucy-Pilates via the website or the Facebook Group. If I wish to continue without such advice I do so entirely at my own risk. I confirm that I have read, fully understood and answered the above questions honestly. I understand that Pilates34Tribe cannot be held responsible for any injuries or ill health arising from my participation in the exercise programme. I understand that I will be participating in physical activities that will include Pilates exercises, stretches and strengthening exercises as well as other physical activities which may, or may not, be suitable for me as an individual. I realise that in participating in these activities I may be at risk of injury and even the possibilty of death. I hereby confirm that I am participating voluntarily and agree to exercise with my personal safety as a priority. Consent Agreement* I agree to the statement above.CAPTCHA
