New Client Form

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New Client Form_Waiver

Please ensure you have filled out the form to the best of your ability. Form and waiver must be submitted prior to your first class or appointment with Brooke.

Email *

First Name *

Surname *

Phone *

Address *

DOB *

YYYY

Gender *

Female

Male

Prefer not to say

Emergency Contact Name and Phone Number *

Health Practicioner Name and Phone Number *

Do you frequent an Allied Health Service? *

Chiropractor

Physiotherapist

Occupational Therapist

Exercise Physiologist

None

Other:

What is your profession? *

How many hours per day do you sit at a desk? *

How often do you exercise? *

Daily

Weekly

Monthly

What is exercise?

Other:

How do you move your body? What form of exercise do you underake? *

Medical history *

Headaches

Migraines

Loss of sensation OR poor circulation

Anxiety

Poor concentration

Poor coordination

Tinnitus

Fatigue

Learning difficulties

Stress

Shortness of breath

Wheezing

Asthma

Sinus

Heart palpitations

Fluid retention

High blood pressure

Low blood pressure

Heart attack

Back pain

Joint pain

Osteoperosis

Osteoarthritis

Rheumatoid Arthritis

Canal Stenosis

Schuermans

Spondylolisthesis

Scoliosis

Stroke

Diabetes

Whiplash

None. I have no medical implications

Other:

Required

Medical history other?

Have you had surgery? Please list details

Please indicate why you are making this appointment? Give specific location of pain if you have any. *

Do you smoke? *

Yes

Are you pregnant? *

Yes

If female and have delivered children please indicate birth story

Do you have any movement goals you would like to achieve by attending Focus Pilates and Massage *

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