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CLIENT ENROLMENT FORM

PART 1 - YOUR BACKGROUND AND YOUR HEALTH

1. Does your work/sport involve any of the following?
2. Will this be the first time you have practised pilates?
If NO, have you previously attended:
Number of classes attended previously:
3. Has your doctor ever said that you have any sort of heart trouble or defect?
4. Do you feel pain in your chest when you undertake physical activity?
11. Is your blood pressure:
12. Have you had major surgery in the last 10 years?
13. Have you had minor surgery in the last two years?
14. Do you suffer from Asthma, Diabetes or Epilepsy?
15. Have you ever been told you have Arthritic joints, Osteoporosis, or any bone or joint problem that may be made worse by exercising?
16. Do you suffer from back or neck pain?
17. Do you have pain or restricted movement in any other joints (e.g. hip, knee, ankle, shoulder)?
18. Have you ever been diagnosed as Hypermobile (excessibe joint mobility)?
19. If you answered 'Yes' for questions 14-18, do you have medical permission to exercise?
20. Are there any movemens that cause you pain?
5. Are you, or could you be pregnant now?
6. Have you been pregnant in the last six months?
7. If you have had a baby, how was it delivered?
8. Do you often get headaches?
9. Do you lose your balance because of dizziness or do you ever lose consciousness, feel faint or dizzy?
10. Do you have high blood pressure?
21. Are you taking any drugs or medication which may effect your ability to exercise?
22. Have you ever been recommended to take up pilates by a specialist practitioner?
If YES, by your:
23. Do you hereby give us permission to contact them?

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 questions 3-21 above, we advise you consult with your medical practitioner before you start Pilates Classes. Please give further relevant details below, in confidence, to any questions you ticked YES.

 

Are there any factors your teacher should be aware of that may prevent you from regularly attending classes (such as child care, lack of transport, shift work)?

PART 2 - YOUR AIMS

PART 3 - IMPORTANT INFORMATION

Please advise us before commencing any session if, for any reason, your health or your ability to exercise changes.

 

It is inadvisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special arrangement with your teacher. It is also wise to wait six weeks after the birth before resuming exercise.

 

Pilates exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting Pilates sessions.

 

These sessions are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of the exercises, you should refer back to your medical practitioner. The teacher can accept no liability for personal injury related to participation in a session if:

 

• Your doctor has, on health grounds, advised you against such exercise
• You fail to observe instructions on safety or technique
• Such injury is 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 body’s 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 a previous session.

 

I understand that Pilates exercises involve hands-on correction and I hereby consent for my teachers to work in this way.

 

I confirm that I have read and understood the above advice and that the information I have given is correct.

 

I confirm that my teacher may use the contents of this form, and any other information I may later provide, for teaching purposes, and that this information:
• will be used in confidence and stored securely
• 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 Pilates-related activities, and understand that I have the right to withdraw this ‘consent to be contacted’ at any time.

Thank you. Your content has been submitted

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