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Medical form 2023
Please could you complete the attached form 2023 thank you.
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Email
*
Your email
Name
Your answer
Telephone number (optional)
Your answer
Age
40's or under
50's
60's
70 +
Clear selection
Whats the reason you want to come to a session? what do you hope to gain?
Your answer
Do you have medical or physical conditions ? if yes please list them below
*
Your answer
What is your doctors surgery and number? If you are on any medication please list below & let me know what it is for.
*
Your answer
What's the biggest frustration about your injury / medical condition? (if appropriate) and If you have been to see a chiro / dr / physio regarding an ongoing injury/ condition please give details below
Your answer
How did you originally hear about the class
*
Google
Recommendation
Keynsham Voice
Wellbeing college
Poster
Facebook
Other
can't remember
Other:
Required
I'm happy for Sandhya to touch me during the class if appropriate to show positioning
yes
no
Not sure
Other:
Clear selection
Which class will you be attending?
Monday 5.45 Pilates
Tues 9.30 Pilates
Tues 10.30 relax tone and stretch
Tues 11.30 Yoga
Wed 9.30 Pilates
Wed 10.50 Meditation
Thursday 5.30 Yoga
Thur 7.00 Yoga
Sound relaxation
121 session
Wellbeing class
Retreats
Pilates & Relaxation challenge online
Option 14
Other:
If you previously attended a class do you have any comments / reviews on the class and how it has benefited you?
Your answer
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