Intake form — Powerhouse Pilates

About you

Full name *

Date of birth *

Email *

Mobile (WhatsApp) *

Emergency contact name *

Emergency contact number *

Medical aid (optional)

Your goals

What brings you to pilates? *

Have you done pilates before?

Never A few times Regularly

Current activity level

Mostly sedentary Active 1–3× a week Active 4+× a week / athlete

Health screening (PAR-Q)

Answer honestly — a "yes" doesn't stop you training, it helps Mikka adapt the session. If you answer yes to any of the first four, please get clearance from your doctor before your first session.

1. Has a doctor ever told you that you have a heart condition, or that you should only do physical activity recommended by a doctor?

Yes No

2. Do you feel pain in your chest when you do physical activity, or have you in the past month?

Yes No

3. Do you lose your balance because of dizziness, or do you ever lose consciousness?

Yes No

4. Are you pregnant, or have you given birth in the last 6 months?

Yes No

5. Do you have a bone or joint problem (back, knee, hip, shoulder, neck) that could be made worse by physical activity?

Yes No

6. Have you had surgery in the last 12 months?

Yes No

7. Are you currently taking any medication that affects your heart rate, blood pressure, balance or energy?

Yes No

8. Do you have any of these? Tick all that apply.

Diabetes Asthma / breathing condition Arthritis / inflammatory condition Osteoporosis / low bone density Hypermobility / EDS Hernia (any type) Pelvic floor concerns None of these

9. Are you currently seeing a physio, chiropractor, biokineticist or other practitioner?

Yes No

10. Anything else Mikka should know about your body, your history, or what you're worried about?

Consent

I confirm the information above is accurate to the best of my knowledge, and I'll tell Mikka if anything changes. *

I've read the medical disclaimer and terms, and understand pilates is movement coaching, not medical treatment. *

I consent to Powerhouse Pilates storing this information to plan my sessions, as described in the privacy policy. *

Health intake form

About you

Your goals

Health screening (PAR-Q)

Consent