Your Name (required)
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Sex —Please choose an option—MaleFemale
Date of Birth
Occupation
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Emergancy Contact Name & relationship
Emergancy Contact tel. number
1. Does your work/sport involve any of the following? Sitting for long periodsBendingLifting heavy weightsDrivingStandingAny other repetitive action
2. Will this be the first time you have practised Pilates? YesNo
If NO, have you previously attended: Chichester Physio PilatesAt homeOther Studios
Number of classes attended previously 01-45-1011-2020+
3. Has the doctor ever said that you have any sort of heart trouble or defect? YesNo
4. Do you feel pain in your chest when you undertake physical activity? YesNo
5. Are you, or could you be pregnant now? YesNo
6. Have you been pregnant in the last six months? YesNo
7. If you have had a baby how was it delivered? VaginalCaesareanVaginal with intervention
8. Do you get headaches? YesNo
9. Do you lose your balance because of dizziness or do you ever lose consciousness, feel faint, or dizzy? YesNo
10. Do you have high blood pressure? YesNo
If YES, is this regulated by medication? Please give details
11. Is your blood pressure: NormalHighLow
12. Have you had any major surgery in the last 10 years? YesNo
13. Have you had any minor surgery in the last 2 years? YesNo
14. Do you suffer from asthma, diabetes or epilepsy? YesNo
15. Have you ever been told you have arthritic joints, osteoporosis, osteopenia or any bone or joint problem that may be made worse by exercising? YesNo
16. Do you suffer from back of neck pain? YesNo
17. Do you have pain or restrictive movement in any other joints (e.g. hip knee ankle shoulder) YesNo
18. Have you ever been diagnosed as hypermobile? (excessive joint mobility?) YesNo
19. If you have answered "yes" for questions 14 - 18 do you have medical permission to exercise? YesNo
20. Are there any movements that cause you pain? YesNo
21. Are you taking any drugs or medications which may affect your ability to exercise? YesNo
22. We have been recommended to take up Pilates by a specialist practitioner, if so who?
23. Do you hear by give us permission to contact them? YesNo
Practitioners name and telephone number:
Please list any health problems you suffer, not already mentioned, that may affect your ability to exercise.
If you have answered yes to any of the questions 3–21 above, we advise you to consult with your medical practitioner before you start Pilates classes. Please give her the relevant details below, in confidence, to any questions you ticked yes.
24. So your reasons for taking up Pilates?
25. What health or physical goals would you like to achieve over the next three months?
26. What long-term health or physical goals would you like to achieve over the next 12 months?
Please advise us before commencing any session if, for any reason, your health or your ability to exercise changes. It is in advisable to do Pilates between weeks 8 to 14 of pregnancy, and less by special arrangement with your teacher. It is also wise to wait six weeks after the birth before resuming exercise.
Pilates exercise a very safe but, as with any forms of physical exercise, it is prudent to consult your doctor before starting Pilates sessions.
These sessions are not suitable for medical counselling or treatment. If you have any doubts about the suitability of the exercise, you should refer back to your medical practitioner. The teacher can except no liability for personal-injury related to participation in a session if: • your doctor has, on health grounds, advised you against such exercise • you fell to observe instructions on safety or technique • such injuries caused by the negligence of another participant in the class/studio
Exercise should be performed at a pace which feels comfortable for you. Pain is the bodies warning system and should not be ignored. Please inform your teacher immediately if you feel any discomfort during a session. Please also inform your teacher if you felt any discomfort after previous session.
I understand the Body Control Pilates exercises involve hands on correction and I hear by consent for my teacher to work in this way. I confirm that I have read and understood the above advice and that the information I've given is correct. I confirm that my teacher may use the contents of this form, and any information I may like to provide, for teaching purposes and this information: • will be used in confidence and stored securely • we will not in any circumstances be shared with a third-party without my written consent unless that party is another Pilates teacher who will teach me • may be retained by the teacher for a period of time such as complies with professional, legal and insurance requirements that they must fulfil.
I confirm agreement for my teacher to contact me with information on classes and other places related activities and understand that I have the right to withdraw this "consent to be contacted" at any time.
Please use the mouse if on a computer to add your signature or your finger if using a tablet or mobile.
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