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Upper Crossed Syndrome Workshop

Health Questionnaireposturein2025-03-09T09:01:53+01:00

Health Questionnaire

Thank you for choosing to work with Maria for your Pilates journey. To ensure your sessions are safe, effective, and tailored to your needs, please take a few minutes to fill out this health questionnaire.

Personal Information

Full Name: *

Date of Birth: *

Phone Number: *

Email Address: *

Emergency Contact (Name & Phone): *

Medical History

1. Are you currently under medical supervision? *

Yes

If yes, please provide details: *

2. Do you have any chronic or recent injuries, illnesses, or surgeries? *

Yes

If yes, please specify: *

3. Have you been diagnosed with any of the following conditions? *

Back pain

Herniated disc

Osteoporosis/Osteopenia

Arthritis

Scoliosis

Joint replacement

Heart condition

High/Low blood pressure

Diabetes

None of these

Other:

4. Are you currently pregnant or postpartum *

Yes

5. Do you have any mobility restrictions? *

Yes

If yes, please explain: *

6. Are you currently taking any medications? *

Yes

If yes, please list: *

7. Have you been diagnosed with any postural imbalances? (eg, scoliosis, lordosis, kyphosis): *

Lifestyle & Exercise History

1. How would you describe your current activity level? *

Sedentary

Moderate

Active

2. Do you currently participate in other forms of exercise or physical activity? *

Yes

If yes, please list: *

3. Have you practiced Pilates before? *

Yes

If yes, for how long and what style? *

4. What are your primary goals for Pilates sessions? (e.g., strength, flexibility, pain relief, posture improvement): *

5. Are there specific movements or exercises you find challenging or uncomfortable? *

Yes

If yes, please specify: *

6. What do you do for work?: *

7. Do you have difficulty with balance, coordination, or mobility?: *

8. Do you spend long hours sitting or standing during the day?: *

Additional Information

Is there anything else you'd like your instructor to know to ensure a safe and effective session?

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unique and personalized approach

Structural Pilates

Maria posture in movement - Pilates & personal training

UPPER CROSSED SYNDROME WORKSHOP

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Health Questionnaire

Larchmont
New York 10538

info@mariapostureinmovement.com