Pilates Health Questionnaire & Consent Form

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PRIVATE AND CONFIDENTIAL

GENERAL CLIENT DETAILS FOR ONLINE AND STUDIO CLASSES

Client name *

Date of Birth *

YYYY

Email address *

PILATES AIMS

Have you done Pilates before? *

Yes

What aspect of your health would you like to concentrate on? *

Core Stability

Flexibility

Strength

Stress Management

Posture

Relaxation

Rehab

Other:

ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING CONDITIONS?

Low Back Pain *

Yes, If YES please give further details in section 'Other'

Other:

Pelvic Pain *

Yes, If YES please give further details in section 'Other'

Other:

Any other spinal conditions *

Yes, If YES please give further details in section 'Other'

Other:

Do you have pain or restricted movement in any of your joints? *

Yes, If YES please give further details in section 'Other'

Other:

Heart Problems *

Yes, If YES please give further details in section 'Other'

Other:

High or Low Blood Pressure *

Yes, If YES please give further details in section 'Other'

Other:

Epilepsy (Grand Mal Seizures) *

Yes, If YES please give further details in section 'Other'

Other:

Continence concerns *

Yes, If YES please give further details in section 'Other'

Other:

PREGNANCY

Are you pregnant? *

Yes, If YES please state how many weeks in section 'Other'

Other:

Have you had any complications with your pregnancy? *

Yes, If YES please give further details in section 'Other'

Other:

SURGERIES OR INJURIES

Have you had major surgery in the last 10 years? *

Yes, If YES please give further details in section 'Other'

Other:

Have you had minor surgery in the last 2 years? *

Yes, If YES please give further details in section 'Other'

Other:

Have you had any injuries in the last 2 years? *

Yes, If YES please give further details in section 'Other'

Other:

P3 PILATES PARTICIPATION INFORMED CONSENT SHEET

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

It is inadvisable to do Pilates between 8 to 14 weeks of pregnancy, unless by special arrangement with your teacher. It is also wise to wait 6 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 counseling or treatment. If you have any doubts about the suitability fo 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 to you. PAIN is the body's warning system and should NOT BE IGNORED. Please inform the teacher immediately if you feel any discomfort during a session. Please also inform the teacher if you felt any discomfort after a previous session.

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

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

I consent.

Required

Date *

YYYY

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