Client registration and Health questionnaire

Name

First NameLast Name

Date of birth

Date

Gender

Address

Street Address

Street Address Line 2

CityCounty

Postcode

Email

example@example.com

Primary Contact Number

Area CodePhone Number

Other Phone Number (optional)

Area CodePhone Number

What is your occupation?

e.g. sales, retired

Do you spend significant time doing any of the following?

Describe any sports or physically demanding hobbies you have?

Have you ever had to stop or modify your sports / hobbies?

Please give details

Do you smoke?

How many per day?

Describe any previous Pilates experience you have

e.g. pre-natal classes about 4 years ago

Health goals

Draw on the image to show areas you would like to improve

Health conditions

Please give details of ticked condition(s)

Physical Activity Readiness Questionnaire (based on 2019 PAR-Q+)

Has your doctor ever diagnosed you with a heart condition or high blood pressure?

Have you been diagnosed with any other chronic medical condition?

Please give details of other medical conditions

Are you currently taking prescription medicine for any chronic medical condition?

Please give details of medicine(s) & condition(s)

Do you feel chest pain at any time?

Do you lose balance due to dizziness OR have you ever lost consciousness in the last 12 months?

Has your doctor ever said that you should only do exercise under medical supervision?

Do you have (or had in the last 12 months) a bone, joint or soft tissue (muscle, ligament or tendon) problem that could be made worse by becoming more physically active?

Please give details of what condition(s)

Please add any other information that you think I should know

Please contact me to discuss your PAR-Q answers further before beginning my classes

Informed consent

I hereby state that I have read, understood and answered honestly the questions on this form to the best of my knowledge. I wish to participate in Pilates exercise programmes which I understand are designed to improve muscle tone and strength, endurance and flexibility and may include physical activities such as stretching, using a resistance band and other small equipment.

I realise that in participating in these activities I am likely to experience different levels of intensity over varying lengths of time that may lead to some pain or discomfort depending on my level of fitness, at which point I should stop the activity and notify the instructor. I agree to ask questions if I am not clear about any of the exercises and understand that when undergoing intense physical activity I may be at risk of injury and even the possibility of death. I hereby confirm that I am participating voluntarily and at my own risk.

By submitting this form I understand and give my consent that the details I have provided will be processed and stored in accordance with the EU GDPR solely for the purposes of managing my participation in the Pilates classes, e.g. being contacted in relation to Pilates classes that I may wish to attend and any Physiotherapy services that I may request. I also understand that I may request to have my contact details deleted should I no longer require your services, but some minimal personal identification data will be held on file for statutory record-keeping purposes for a duration in line with currently applicable legislation.

[Note that when you submit this form all the details you have entered here will be encrypted before transmission]

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