Your details Your name Your email address Your date of birth Your address Your postcode Telephone (primary) Telephone (secondary) Your email GP name and address Next of kin Telephone (nok) How did you hear about me Your requirements What aspect of health would you like to concentrate on? Why have you decided to commence Pilates? Core StabilityFlexibilityPosturePelvic Floor TrainingRelaxation Toning What are the three main aims that you are hoping to achieve with your Pilates program? Your activity levels Are you currently working? NoYes What is your occupation? Does your occupation involve any repetitive movements or prolonged postures? NoYes If yes, please briefly explain: Are you involved with any other sports and/or hobbies? NoYes If yes, please briefly outline: Medical questionairre Are you currently experiencing OR ever been diagnosed with any of the following conditions? Heart problems NoYes High/Low BP NoYes Circulatory problems e.g. blood clots NoYes Thyroid problems NoYes Diabetes NoYes Respiratory conditions e.g. asthma NoYes Epilepsy (Grand mal seizures) NoYes Upper back pain NoYes Pain at the front or back of your pelvis NoYes Any other muscles/joint conditions NoYes Do you have any children? NoYes Do you have any children? Do you have any Lower Back Pain (LBP)? NoYes If yes, approx. how many previous episodes of LBP have you had? n/a1-23-56-1010+ Have you had any recent injuries or surgery? NoYes Do you have any allergies? NoYes Any other relevant history or notes If yes, please briefly outline: Pilates participation informed consent The Pilates program will begin at a low level and will be advanced in stages depending on your fitness level. Pilates sessions may be stopped because of signs of fatigue or strain. It is important for you to realise that you may stop when you wish because of feelings of fatigue or other discomfort. There exists the possibility of certain dangers when exercising. They include abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances, heart attack, stroke or death. Whilst every care will be taken, it is impossible to predict the body’s exact response to exercise. Efforts will be made to minimise these risks by evaluation of preliminary information relating to your health and by observations during exercising. Trained personnel are available to deal with unusual situations that may arise. I understand that the Pilates program will be specifically designed as a personal training plan, and will take into account details given my health questionnaire and assessment. Therefore, this program of exercise should only be undertaken when in a Pilates class, or when I have been given specific instructions to exercise on my own. By providing your e-mail address you will receive a fortnightly e-newsletter with tips, advise, education and occasional offers towards classes. Please tick here if you do not wish to receive this Please note a full fee may be applicable if less than 24 hours notice is not given for all cancellations. I confirm that the above is correct to the best of my knowledge