Pilates Group Class Health Form

Date

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal Code

Phone Number

Area CodePhone Number

Emergency Contact Name

Emergency Contact Number

1. Do you have a heart condition or been told to check with your doctor before undertaking physical exercise?

YesNo

1a. If yes, please give details below..

2. Have you ever suffered from chest pains during physical activity or at rest?

YesNo

2a. If yes, please give details below..

3. Have you ever suffered from high or low blood pressure or a heart condition?

YesNo

3a. If yes, please give details below..

4. Do you ever feel faint or dizzy?

YesNo

4a. If yes, please give details below..

5. Do you have a back, pelvis or other joint or bone problem that may be made worse by exercise?

YesNo

5a. If yes, please give details below..

6. Do you suffer from diabetes?

YesNo

6a. If yes, please give details below..

7. Have you had any operations in the last five years?

YesNo

7a. If yes, please give details below..

8. Are you pregnant or recently had a baby?

9. How would you rate your pelvic floor strength out of 10?

10. Do you have any injuries, aches or pains? Please give details of new and old..

11. Have you ever suffered from any of the following?

11a. If yes, please give details below..

12. Are you on any medication?

YesNo

12a. If yes, please give details below..

13. Have you taken part in any Pilates training in the past?

14. Do you have any other reasons why you should not take part in physical activity?

I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance training and stretching. I realise that my participation in these activities involves the risk of injury, abnormalities of blood pressure or heart attacks as well as other side effects. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me. I understand that my trainer (Tiffany Jansen) shall not be liable for any damages arising from personal injuries sustained by the Client while during and/or from a Pilates programme. The Client participates at his/her own risk. The Client assumes full responsibility for any injuries or damages which may occur during and/or after training.

I understand that my instructor (Tiffany Jansen) will need to be informed of any changes in my condition. I confirm that I have acted on any issues arising from the questions on this form, and have obtained medical advice where required (as indicated on the form).

Please tick to give permission to be added to our mailing list for further information on classes.

Client Signature

Date

If you answered YES to one or more questions from 1-6 please talk to your doctor BEFORE you become more physically active. Discuss with your doctor which kinds of activities you wish to participate in.

I have taken medical advice and my doctor has agreed that I should exercise. Please sign below.

Client Signature

Date

Health Questionnaire

Personal Information

Health

INFORMED CONSENT