Exe Pilates Enrolment Form

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Client Physical Activity Readiness Questionnaire

Email *

Important - please read

Before commencing any exercise session with Exe Pilates, please inform us if your health and ability to exercise changes at any time.

Pilates is generally a very safe form of exercise suitable for all ages and abilities, but if you do have a complex, underlying health condition and require medication it is prudent to always consult your GP before beginning Pilates. If you have any doubts about the suitability of Pilates classes you should always refer to your medical practitioner. It is inadvisable to do Pilates between weeks 8-14 of pregnancy - so please first seek advice from your midwife or designated medical professional before exercising.

Our Pilates teachers can accept no liability for personal injury related to participation in a session if:
- your doctor or medical practitioner has advised you against such exercise on health grounds
- you fail to observe instructions on safety or technique

Class participation requires you to perform exercise at a pace that feels comfortable to you. Adaptations are readily available to accommodate individual needs and abilities. Never work to pain and please always stop and inform the teacher if you feel significant or increasing discomfort during a session.

Under the General Data Protection Regulation May 2018 we are required to inform clients that we have a privacy policy which is readily available for you to review at https://exepilates.co.uk/privacy-policy.

We are required to collect and retain relevant information and records relating to each client for the purpose of advising, supervising and modifying an exercise programmes to ensure their safety and wellbeing.

Clients have the right to receive a copy of the information we hold and have the right to ask for information to be removed or amended if it is thought to be inaccurate. Requests should be made in writing to Exe Pilates or by email to: Info@exepilates.co.uk

Full name *

Date of birth *

YYYY

Address and postcode *

Primary contact number *

Primary email address - if none, please type "none" *

Alternative contact number

Emergency contact details - name and mobile/telephone number *

How did you find out about Exe Pilates? *

Recommendation from another member of Exe Pilates

Recommendation from friends and family

Recommendation from a medical professional e.g. GP, physiotherapist

Website search

Social media e.g. Facebook, Instagram

Other:

Required

Were you advised to take up Pilates? *

Yes

If yes, who advised you?

Physiotherapist

Medical professional

Friend or family member

A professional therapist

Other:

Is this your first experience of Pilates? *

Yes

If no, please provide more details about your previous experience of Pilates

Does your daily routine involve any of the following? *

Sitting for long periods

Lots of bending and twisting

Lifting heavy weights

Driving

Standing

None of the above

Other:

Required

What physical activities do you participate in regularly during an average week and for how long? *

Has a doctor or specialist ever advised you not to participate in any type of physical activity? *

Yes

If yes, please provide more details about why.

Have you ever been diagnosed with or experienced any of the following? *

Abnormal blood pressure that requires medication

Diabetes

Epilepsy

Cardio-vascular based issue

Heart attack

Stroke

Regular spine or neck pain that has required medical attention

Hypermobile joints

Osteoporosis or osteopenia

Surgical repair to any joint or soft tissue

Major surgery in the past 10 years e.g. transplant, open heart surgery

Breathing issues such as asthma or any type of recurring lung condition

Autoimmune condition

A progressive neurological condition such as Parkinsons and MS

None of the above

Other:

Required

If you have indicated that any of the above are relevant to you, please provide further details including the approximate year of diagnosis, whether you require medication and when the last episode was.

Do you ever feel pain when you exercise? *

Yes

If yes, please provide further details to describe where the pain is situated and the type of exercise that brings on the pain.

Are you pregnant or have you had a baby in the last 6 months? *

Yes

Have you had any surgery or operations in the past 2 years? *

Yes

If yes, please provide further details.

Do you regularly feel dizzy or faint? *

Yes

If yes, please provide further details e.g. under what circumstances, how often.

Do you have any restricted movement in your joints e.g. spine, shoulder, neck, hip, knees? *

Yes

If yes, please provide further information e.g. which joint, how long you've noticed the restriction, which side, what type of movements do you find restricted.

Please detail any health issues or any prescribed medication that you have not already mentioned that you believe may affect your ability to exercise.

Broadly, what are your reasons for taking up Pilates? *

What health or physical goals would you like to achieve longer term? *

Confirmation of information accuracy *

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

Required

Private Policy consent *

I have read and understood Exe Pilates' Privacy Policy and am happy for the information I have supplied to be recorded and retained for appropriate use in accordance with the General Data Protection Regulation May 2018.

Required

Date when confirmation and consent has been given. *

YYYY

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