Pilates with Snow
Pre-Exercise Screening
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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Month
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Day
Year
Date
Occupation
Have you done Pilates before? If so for how long and what level?
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What are your goals for doing Pilates?
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Do you exercise regularly? If so, what type and how often?
Do you have any medical conditions (Including but not limited to) Asthma, High or Low Blood Pressure, Cardiovascular Disease, Cancer, Diabetes, Chest Pain, Fibroids, PCOS, Digestive Issues? Please give as much detail as possible
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Do you experience back pain? If so upper, mid, lower? Any associated nerve pain or disc issues?
Do you experience headaches? If so, how frequently?
Do you have Osteoporosis or Osteopenia?
Do you have Arthritis? If so, what type and where does it affect you?
Do you experience anxiety, depression or other neurodivergent conditions?
Do you have any neurological conditions such as Parkinsons, MS, Cerebral Palsy, CMT, Stroke, Epilepsy, Motor Neuron Disease? If so please give details.
Do you have any history of injuries, surgeries or hospitalisation? If so please give details.
Is there any other relevant information you would like to provide?
Disclaimer: I understand that I must inform my instructor of any pain or discomfort, and that if any exercise causes increase to pain or discomfort I will stop immediately. I understand this is my responsibility to keep my instructor informed and updated at all times. I understand that, as with any physical activity, there are inherent risks including DOMS (delayed onset muscle soreness). I agree to keep my instructor informed of any medical conditions or musculoskeletal pain. I confirm that the medical information above is true and correct to the best of my knowledge. I understand that if any of the above conditions apply I may need to seek medical clearance before undertaking Pilates. I declare that I am undertaking these classes at my own risk, and that my physical and medical well-being is my sole responsibility. I hereby release Pilates with Snow from any liability for damage, injury or expense that result from my participation in these classes. By entering my full name below I declare that I have read and understand the conditions above, and have completed all questions to the best of my knowledge. Signature
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